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I 



^:i«^^Vv-.j' ' N 



1 



THE 



NORTHERN 

JOURNAL OF MEDICINE ; 



MONTHLY SURVEY 



OF THE 

PROGRESS OF MEDICAL KNOWLEDGE 
AT HOME AND ABEOAD. 

SDITID BT 

WILLIAM SELLER, M.D., 

VSLLOW OF THB BOVAL OOLUMS OP PHYSICIANS, LSCTimBR ON BfATNItlA IfNDIOA AND DirrSTICS, 

AND 

T. LINDLEY KEMP, M.D.; 

WITH THB ASSISTANCE OF A BODY OF GENTLEMEN ENGAGED IN THE PRACTICE 
AND TEACHING OF MEDICINE. 



VOL. I. 




EDINBURGH: 

PUBLISHED FOR THE PROPRIETORS ; 

AND SOLD BY OLIVBR & BOYD, EDINBURGH; DAVID ROBERTSON, GLASGOW; LEWIS 
SMITH, ABERDEEN; SIMPEIN, MARSHALL, & CO., LONDON; W. CURRY, JUN., & CO., 
DUBUN; GAUGNANIi PARIS; HIRSOHWALD. BERLIN; AND ALL B0OKSELLER& 

1844. 



Printed by (Jliver it Boyd, 
TwMddale Coart, Hifh StrMt-, Edinburgh. 



THE 

NORTHERN 

JOURNAL OF MEDICINE. 



No. I.— MAY 1844. 



Part I.— ORIGINAL ARTICLES. 



On the Employment and Action of Digitalis in certain Diseases 
of the Heart. By William Henderson, M.D., Professor 
of General Pathology in the University of Edinburgh. 

A REMEDY so long and so habitually resorted to, and so much 
prized, in the treatment of diseases of the heart, as digitalis, may 
be supposed to have been so thoroughly studied, and to be so 
weU understood, in all its therapeutic capabilities, as scarcely to 
afford occasion or ground for remarks having any pretension to 
novelty or importance ; and yet, a glance at the opinions which 
are entertained of the manner in trhich its benefits are effected, 
and at the indiscriminate and almost universal recommendation 
of it in organic diseases of the heart, suffices to prove that some- 
thing may still be added to the history of its operations, not 
unworthy of being known. Or perhaps the matter may be more 
correctly stated in a different way, so as that, while it may be 
granted that the effect which digitalis produces on the heart is 
thoroughly understood, it may be still questioned whether the ' 
manner in which different diseases of the heart are influenced by 
that effect has been duly considered or recognised, — ^a mode of 
putting the case which would make the proper title of this com- 
munication, '' The action of different diseases of the heart under 
the influence of digitalis." 

Passing by the alleged temporary acceleration of its contrac- 
tions, the heart may be said, in general terms, to have the fre- 
quency of its motions lessened by digitalis. Such being the case, 
it will hardly surprise any one who is sufficiently acquainted with 
the very signal changes which some diseases of the organ pror 



2 ON THE EMPLOYMENT AND ACTION OF DIGITALIS 

duce on its construction as an hydraulic machine, that a frequency 
of its action, which may be advantageous in certain conditions of 
it, may be very much the contrary in others ; and yet the im- 
portant inference which may thus be demonstrated by morbid 
anatomy is almost universally overlooked in practice. My at- 
tention to this circumstance was first suggested by Dr Corrigan's 
excellent paper, in the Edinburgh Medical and Surgical Journal, 
on Permanent Patency of the Aortic Valves. That judicious 
physician had noticed that the employment of digitalis was not 
so generally useful in that as in most of the other diseases of the 
heart, and my own subsequent experience and observation en- 
tirely concur with his. I do not mean to say that very 
notable advantage is not derived from digitalis in permanent 
patency of the aortic valves, but that beyond a certain degree its 
characteristic operation is so much less beneficial than in the 
other diseases of the heart in which digitalis may be employed, 
or is actually so injurious, that it becomes a highly important 
practical rule to abstain from the prolonged or repeated admini- 
stration of it in the disease in question. 

Patency of the aortic opening, at that period when the ven- 
tricles are being filled, necessarily admits of regurgitation from 
the aorta, the effects of which are an overloading of the left 
ventricle, and gradually an enlargement of it — an enlargement 
so great ultimately, if the patient survive long, as to exceed, often 
to a great degree, that which occurs under any other circum- 
stances. The greatest enlargement of the heart I have seen, 
larger than any other on record, was the consequence of 
permanent patency of the aortic opening. All the chambers of 
the organ had become affected with excentric hypertrophy, and 
to so great a degree that the weight of the empty heart amounted 
to thirty-six ounces two drachms and a half, — above four times 
the average weight of the healthy heart. Such being the 
tendency and issue of that overloaded condition of the organ 
which results from regurgitation from the aorta, it will be granted 
that whatever increases the amount of the regurgitation must 
accelerate the progress of the enlargement. That the less 
frequently the heart beats, the greater will be the opportunity 
for this regurgitation, is sufficiently obvious ; and hence it is that 
the prolonged employment of digitalis cannot but be injurious 
when the aortic valves are not competent for their office. To 
the consideration of other expedients, common in the ordinary 
treatment of organic diseases of the heart, yet unequivocally 



IN CERTAIN DISEASES OF THE HEART. 3 

improper in this, I may advert on a future occasion, and shall 
content myself at present, in reference to what has just been 
stated, with saying that, if true to the extent to which I believe 
it to be true, its importance is very much enhanced by the facts 
that permanent patency of' the aortic valves is one of the most 
common of the valvular diseases of the heart, and is perhaps the 
most easily distinguished during life. 

What a priori discernment and practical observation concur 
in showing to be disadvantageous in the disease which has been 
specified, is capable of being proved by the same means to be 
eminently useful in some other diseases of the heart, and in none 
more than in those of the left auriculo- ventricular opening. To 
these I confine my further remarks for the present. 

Diseases of this opening, although of several kinds, produce 
but two sorts of effects on the drculation ; — either, by merely 
narrowing it, hindering the transmission of blood from the left 
auricle into the ventricle, or, by rendering the leaves of the 
mitral valve insufficient to close it, while the ventricle is con- 
tracting, admitting of a regurgitation of blood into the auricle. 
When either of these occurrences amounts to a considerable de- 
gree, and is of long continuance, hypertrophy of the right 
ventricle supervenes, and then it is that the sufferings from 
dyspncea are developed, and that dropsical effusions are apt to 
take place. The circulation through the heart is materially 
impeded, and the lungs, — partly from this cause, and partly from 
the augmented power of the right ventricle, — ^placed as it were 
between two fires, become overloaded with blood, and distressed 
with the sense of suffocation. And not only so, but the whole 
venous circulation becomes retarded, and congestions occur in 
distant viscera. Superadded to the mere mechanical imperfec- 
tions which result from the diseases of the opening, and the 
hypertrophy of the right ventricle, an increased frequency of 
the actions of the heart very commonly attends, either as a 
permanent occurrence, or as an occasional event dependent on 
bronchitic attacks, and, usually, in proportion to this frequency 
are the distress from dyspncea and the amount of the dropsy. 
Those who are familiar with valvular diseases of the heart must 
have remarked that a very moderate amount of bronchitis is 
enough to excite much suffering from what is called difficulty of 
breathing, but it is certainly not usual to find this ascribed to 
its true cause. Impeded transmission of air into the cells of the 
lungs is commonly considered the source of the evil, though the 



4 ON THE EMPLOYMENT AND ACTION OF DIGITALIS 

dyspnoea is often very great without there being any stethoscopic 
evidence of such impediment ; and, that I am right in ascribing 
it rather to the increased frequency of the actions of the heart, 
appears from the facts that mere muscular exertion, by increasing 
that frequency, suffices to produce or to aggravate the dyspnoea, 
and that a diminution of that frequency through the instru- 
mentaUty of digitaUs suffices to lessen or to remove it. The 
reason why an acceleration of the pulses of the heart excites or 
increases dyspnoea and dropsy in the diseases of the left auriculo- 
ventricular opening is twofold. In the first place, it does so on 
account of the hypertrophic condition of the right ventricle, and, 
in the second, on account of certain occurrences at the diseased 
opening. Thus, when there is narrowing only of that opening, 
the more frequent closings of the valve cause a more frequent 
interruption to the onward motion of the blood ; and, when there 
is a patent state of the opening, a more frequent regurgitation, 
and a greater amount of it in proportion to the quantity of 
blood which has had an opportunity of passing into the ventricle. 
Such being the natural effects of an increase in the frequency of 
the actions of the heart, it is easy to understand how a diminished 
frequency operates in reUeving the disorders which attend on 
the diseases which have been referred to. This operation is 
useful in several ways ; it moderates the force with which the 
blood is propelled into the lungs, and, by the lengthened interval 
between the contractions of the heart, it allows of the left ven- 
tricle being more fully distended in the case of the narrowed 
opening, while it lessens the frequency of the interruptions to 
the passage of the blood, and, in the case of patency of the 
opening, prevents the regurgitation from being so often repeated. 
That these latter circumstances are not visionary, but real and 
efficient, is manifested by the great change which is witnessed in 
the size and force of the pulse at the wrist when the digitalis 
has produced its full effect on the actions of the heart. From 
being very small and feeble before the digitalis has been admini- 
stered, the pulse becomes full and firm when the medicine has 
reduced the number of the contractions of the heart to 40 or 60 
in the minute. Coincident with this change, other important 
improvements occur. The respiration becomes freer and easier, 
the amount of urine increases, and the dropsy begins to disappear ; 
improvements which are due to the bettered circulation through 
the heart, and the consequent diminution of those mechanical 
congestions which had embarrassed the lungs, and hindered the 



IN CERTAIN DISEASES OF THE HEART. 5 

action of the kidneys. In illustration of tHese yiews I subjoin 
two cases, the one of narrowing of the left auriculo-ventricular 
orifice, the other of regurgitation through it, and both with 
hypertrophy of the right ventricle. It will be seen that in 
each, as the heart beat more slowly, the amount of the urine 
increased, and the dyspnoea and dropsy diminished. At first, for 
a few days, in one case, squill and bitartrate of potash were con- 
joined with the digitalis for the purpose of securing a diuretic 
effect with more certainty ; they were speedily omitted, in order 
to show the pupils of the hospital the action of digitalis alone. 
I took the opportunity of stating, that I did not conceive the 
digitaUs to act as a diuretic, in the common sense of the term, by 
augmenting directly the functional activity of the kidneys, but 
inihrectly in consequence of its lessening or removing the venous 
congestion of these organs, in common with that of other viscera, 
in the way I have described. At the same time it was stated^ 
that digitalis has been conceived to have the power of increasing 
the secretion of urine by a more direct influence, perhaps a 
stimulation of the kidneys, since it has appeared to augment the 
quantity of urine sometimes in healthy persons, and has been 
known to produce a similar effect on other secretions, occasionally 
to a very considerable degree, — on the saliva for example. But 
that in the cases in question the medicine could not be supposed 
to have acted in this way, but in that which I have detailed 
above, appeared to be proved by the continuance of the copious 
secretion of urine so long as the effect of the digitalis continued 
to be exerted on the heart, many days after the drug had been 
omitted ; and by the decrease in the amount of urine which 
occurred when the action of the heart rose to its previous 
frequency. 

Case 1. — Narrowing of the Left Auriculo-ventricular Opening. 

Mary McDonald, a widow, aged 60 years. She was admitted 
into the Infirmary on the 19th of February last, and fell under 
my care on the 29th of that month. It had been ascertained 
that twelve years before her admission she had been affected 
with severe pain in the chest, for which she was bled and blis- 
tered, and that since that time she had enjoyed on the whole 
good health until about six weeks before her admission, when, as 
she thought in consequence of exposure to cold, she became af- 
fected with dyspnoea and cough. She had been previously sensible 
of occasional palpitations of the heart, and about the time at 
which she began to suffer, — ^but whether after the dyspnoea came 



6 ON THE EMPLOYMENT AND ACTION OF DIGITALIS 

on or not was not ascertained, — she became a£fected with general 
dropsy. 

The report of the 29th of February is as follows : — The ster- 
num is prominent, the corresponding cartilages of the ribs not so. 
The percussion-sound is pretty good in front, beginning to be 
dull in connexion with the heart between the third and fourth 
left cartilages, and laterally on the right side of the lower third 
of the sternum, from which the dulness extends two inches to the 
left of the bone. The respiratory murmur is superseded a Uttle 
by mucous rattle on the right front. The percussion-sound is 
dull on the left back inferiorly , nearly from the lower angle of the 
scapula, but is moderately good on the right. The respiratory 
murmur is absent over the dull space on the left. Pulse at the 
wrist very feeble and irregular ; in the region of the heart not 
particularly strong. At the wrist the pulsations amounted to 56 
in the minute, and in the region of the heart to 72. She has 
much dyspnoea ; respirations 26. The report on the 1st of March 
is to this effect : — Urine amounts to ten ounces, is loaded with red 
sediment, and has a density of 1023. Pulse in the region of the 
heart is 104, at the wrist 58. It is very feeble and small, but 
pretty regular, in the latter situation. Sounds of the heart are 
free from murmur. Impulse moderate. On the 2d she was 
ordered ten leeches to the sternum, and powders containing each 
two-thirds of a grain of digitalis, two grains of squill, and ten of 
bitartrate of potassa, of which one was to be taken every six 
hours. She had also a draught for the night, containing some 
muriate of morphia and sulphuric ether. She had at this time 
considerable oedema of the lower limbs, and a good deal of 
effusion into the left pleura, 

March 4. The urine began to increase on the 2d, and in the 
course of the last twenty-four hours has amounted to thirty-six 
ounces. Breathing easier. GEdema nearly gone. 

March 5. About seventy ounces of urine. Breathing much 
improved. State of left side much as before. Pulse improved in 
size and strength, — ^at the wrist 56, at the heart 90. All but 
the digitalis to be omitted, of which a grain thrice a-day. 

March 7. Urine 120 ounces. Pulses in the region of the heart 
80, a strong followed quickly by a feeble one ; at the wrist 56, of 
fair strength and size, and not very irregular. 

On the 11th, the pulse was 40 at the wrist, full and firm ; 
and continued from 40 to 42, full and firm, and the urine 
usually from 30 to 90 ounces, till the 19th, though the digitalis 



IN CERTAIN DISEASES OF THE HEART. 7 

was omitted on the 12th. The pulse began to rise in frequency 
after the 20th, and on the 1st of April was at 84, the urine 
amounting to thirty ounces. On the 2d of April, the pulse was 
90, — ^fluctuation and swelling had occurred in the abdomen, and 
oedema in the lower limbs, and the breathing had become again 
very difficult, — ^though the effusion into the left pleura, which 
had disappeared, had not recurred, — and the urine had become 
reduced to fifteen ounces. Two grains of nitre and one and a 
half of squill were prescribed four times a-day, and on the two 
following days the urine amounted to twenty-four and twenty- 
six ounces. Digitalis in doses of a grain thrice a-day was sub- 
stituted on the 4th ; and on the 7th the urine amounted to 64 
ounces, while the pulse ranged between 80 and 92 ; and on the 
10th to 100 ounces, the pulse being 50, of good size and 
strength. On the 11th of April, the pulse was 48, the urine 104 
ounces. The influence of the digitalis on the heart appeared 
to decline afterwards ; and on the 15th the pulse at the wrist 
was 60, small and irregular, in the region of the heart 80, and 
the urine amounted to but 24 ounces. She desired to be dismissed 
at this date. 

Case 2. — Regurgitation through the left auriculo-ventricular 
orifice, and hypertrophy of the right ventricle. 

Mrs Blakie, aged 27 ; admitted into the Infirmary, March 6, 
1844. Eight or ten years ago she was very subject to rheumatism, 
which affected chiefly the lower extremities, but the lesser joints 
in upper extremities also occasionally. About eighteen months 
ago she was confined with her first child, the labour was tedious, 
and required the aid of instruments for its completion. About 
a fortnight after deUvery she had a severe inflammatory affection 
within the chest, shortly after her recovery from which she 
was sensible for the first time of palpitations in the region of 
the heart, greatly aggravated on exertion, and accompanied by 
a good deal of dyspnoea, and sense of constriction across the 
chest. Since that time her sufferings have been gradually in- 
creasing. 

Exertion of any kind, especially that of ascending an emin- 
ence, increases her dyspnoea so much as to oblige her to stand 
still, and produces palpitation of the heart. Her pulse is 90 
at the wrist, very small and feeble. The €xact extent of 
dulness in the region of the heart cannot be ascertained, owing 
to the fulness of the mammae. It begins, however,, fully half an 
inch to the right of the lower half of the sternum, ascends as 



8 ON THE EMPLOYMENT AND ACTION OF DIGITALIS. 

high as the thu*d rib on the left side, and extends to the left 
beyond its natural limits. There is a strong impulse over all 
this surface, and also in the epigastrium; and also a strong 
bellows murmur chiefly in the region of the left ventricle. 
The second sound of the heart at the lower extremity of the 
sternum, on the right side of the epigastrium, and also between 
the second and third left cartilages, is preternaturally clear and 
loud. Both external jugular veins are very turgid, and have 
a sUght single impulse, synchronous with the contraction of the 
ventricles. She has had some swelling of the face, lower ex- 
tremities, and abdomen, for the last three weeks. There is a 
purplish tinge of the countenance; urine said to be between 
two and three pounds, but has not been kept ; density 1022 ; 
distinctly coagulable by heat and nitric acid. A good deal of 
mucous rattle at the lower part of right lung, where 
the percussion-sound is not very satisfactory. She is or- 
dered to have two-thirds of a grain of digitalis thrice a-day. 
On the 10th, the pulse was 80, and fuller ; the urine 40 ounces ; 
the breathing easier; and the oedema considerably less. On 
the 11th, the urine was 68 ounces, of density 1015, and les» 
coagulable ; the pulse 72, and of fair size and strength, — ^all the 
dropsical symptoms diminished. On the 12th, urine 48 ounces, 
pulse 72, of good size and strength. Nausea having occurred, 
the digitalis was omitted, and she had some squill powder given 
her for two days. On the 13th, the pulse continued of good 
size, not exceeding 80, — ^the respirations were easy, and the 
urine amounted to 58 ounces. She was dismissed in about a 
week after, having experienced great reUef since her admission. 
Latterly her complaints were returning, but family circum- 
stances prevented her remaining longer. 



Illustrations of Congenite Syphilis. By William Campbell, 
M.D., Consulting Physician- Accoucheur to the Edinburgh 
Maternity Hospital, and Lecturer on Midwifery, &c. 

Though not a few opportunities occur to those toiling in the 
same vineyard with myself, to satisfy them that a father, whose 
system is contaminated with syphiUs, from this complaint having 
been imperfectly eradicated, may so infect his oflfspring that it 
shall die in utero, or if born alive, exhibit evidences of disease 



ILLUSTRATIONS OF COMOENITE SYPHILIS. 9 

at or some time after birth ; yet as this opinion is called in ques- 
tion in a recent work of reputation,* I am induced to record the 
following illustrations and remarks in support of a belief which 
appears to me to have been long and well established. In 1823, 
I was requested to attend, in her second confinement, Mrs C, the 
lady of one of my brethren, then six months advanced in her 
pregnancy ; and in a few weeks thereafter she was deUvered of 
a male child, which Hved only eight hours. It presented no 
morbid appearance, nor was its development less than that of 
other foetuses whose residence in iUero was of similar duration. 
No cause was assigned for the premature labour ; and I was now 
informed that in her previous confinement the birth was also 
premature, and that the infant survived only a few hours. In 
the summer of 1824, I again attended this lady, when labour 
supervened in the seventh month ; but on this occasion the foetus 
was dead ; and from the extent of decomposition, and the infor- 
mation derived from the parent, hfe must have been extinct for 
more than ten days. 

After these repeated misfortunes I resolved on an inquiry, 
from which, owing to its delicate nature and the respectability of 
the party, I had hitherto been deterred. The gentleman was a 
young physician, and I ascertained that about six months previous 
to his marriage with a young and amiable lady, he contracted 
what appeared to himself and another junior member of the pro- 
fession, a chancre. After employing ^e usual means, and con- 
sidering the disease removed, he married. At the period of this 
investigation there was not in either parent the least evidence of 
syphilis in any form, — ^nay, both the individuals enjoyed perfect 
health. In the foregoing case the gentleman was salivated ; the 
lady also, as a matter of precaution, took a grain of calomel daily, 
for eleven days, when the gums became aflFected to a much greater 
extent than was intended. When the uterus was restored to its 
unimpregnated condition, this lady again conceived, advanced to 
the usual term of gestation without any tendency to premature 
uterine action, and was deUvered of a vigorous male infant, free 
from any syphilitic taint. Therfe was no more issue, for the 
father died within a year from this birth; 

I shall add but one more illustration, for siich oases are so 
familiar to those of our brethren who devote their attention to 
obstetric practice, that it would be superfluous to multiply them. 

* Acton, Complete Practical Treatise on Venereal Diseases, p. 404. 

B 



10 ILLUSTRATIONS OF CONGENITE SYPHILIS. 

In the autumn of 1843, I was consulted hj a lady from the 
country, ten weeks advanced in her fourth pregnancy. Her first 
infant was born in the early part of the eighth month of gestation, 
was delicate, and lived eleven days. The delivery was attended 
by a profuse discharge of liquor amnii. Her second birth hap- 
pened in the seventh month, the infant surviving only an hour 
and a half; and her third delivery happened in the sixth month, 
when a foetus much decomposed was produced. After careful 
inquiry, I satisfied myself that the lady never had any syphilitic 
symptoms. Before I could decide on a suitable plan of treatment, 
I requested an interview with the husband, from whom I learned 
that about 23 years previously, and 17 years before marriage, 
he had syphilis repeatedly ; and though assured to the contrary, 
his impression always was that the disease had not been com- 
pletely removed. These parties were apparently in perfect health. 
I determined on exhibiting mercury to the gentleman, and he was 
accordingly twice mildly salivated. But I hesitated at first to order 
this medicine for the lady, lest the uterus might be excited, and 
the ovum thrown oflF. Proceeding, however, upon the belief, 
from what happened in her three former gestations, that the 
foetus would be destroyed unless mercury were exhibited, and 
that there was a chance the medicine, under prudent manage- 
ment, might not occasion premature expulsion, I determined to 
salivate the lady also. She was twice salivated, after which she 
enjoyed excellent health ; and imtil the seventh month she ad- 
vanced in her pregnancy without even a tendency to premature 
uterine action. From tihis date, however, there were frequent 
threatenings of premature expulsion, which repeatedly required 
the abstraction of blood, and doses of from 80 to 100 drops sol. 
mur. morph. to allay them. At the close of the eighth month 
labour supervened, when a hving, healthy, small female foetus 
was produced. 

I have also met with repeated instances where, after minute 
inquiry, and acknowledged contamination on the part of the fe- 
male parent, I have been satisfied that she alone was to blame 
for a series of misfortunes such as have now been related. In 
several of these instances, the mothers, after positively denying 
ever having had syphilis, afterwards paid me confidential visits, 
to inform me as a profound secret, that they had had this disease 
before marriage. These individuals, likewise, after the admini- 
stration of mercury, had a living progeny. 

In the present age, when it is fashionable with some of our 



ILLUSTRATIONS OF CONGENITE SYPHILIS. 11 

brethren, in their morbid avidity to acquire a character for ori- 
ginality, to deny even the evidence of their own senses, we have 
been told that the production of a living healthy progeny, in 
such cases as those now referred to, is to be ascribed, not to the 
eradication of syphilis, but to the induction of some other change 
in the system. All that need be said, however, in reply to this 
objection is, that such facts as the foregoing, since they must 
have been observed by every practitioner extensively engaged 
in this department of the profession, are of too stubborn a nature 
to be set aside by reasoning or sophistry. From the Graafian 
vesicle being a part of the female parent, and the ovulum after 
fecundation being dependent for its development on the fluids 
derived from her system, it will readily be admitted that the 
progeny will be healthy or diseased according to the condition of 
the materials furnished for its support. But we cannot so easily 
comprehend the transmission of syphilis from the male parent to 
the product of conception. But although we can no more explain 
this point than we can the transmission of mental peculiarities, 
sunilitude of features, gout, scrofula, phthisis, cancer, and super- 
numerary fingers and toes, yet it would be absurd to call its 
reaUty in question, when such glaring and numerous facts are so 
frequently brought under our notice. 

Dr Acton is also sceptical as to the influence of syphilis in de- 
stroying the foetus or producing abortion ; and in support of his 
belief he refers to information derived from prostitutes, who 
were inmates of the Parisian Venereal Hospital during his at- 
tendance at this institution. Though ready to do justice to every 
man's honest opinion, I would say that information from the 
source referred to is, to say the least, questionable ; secondly, 
that the field for observation was far too limited, considering that 
on an average not more than six prostitutes in one thousand con- 
ceived in the course of one year, according to the investigations 
of Duchatelet ;♦ and, thirdly, that opinions based on such data 
cannot be put in competition with the experience of men who have 
been half a century or more engaged in practice. That in occa- 
sional instances a foetus much contaminated with syphilis will be 
retained to the full period of utero-gestation, and even appear 
plump and healthy for days or indeed weeks after birth, must 

• " En r^BUmant toutes ces reponscs qui m'ont 4i4 faites, et ce que j'ai trouvtf 
dans quelques livres anciena et modemes, j'ai du titer cettc conclusion, que miUe 
prostitutes fournissent h peine six accouchemens dans le courant d*une ann^e." 
Tome L p. 230. 



12 ILLUSTRATIONS OF CONGENITB SYFHILIS.^ 

have been noticed by all obstetric practitioners of experience ; 
but such cases only constitute the exceptions to the general rule. 
This circumstance, though undeniable, we cannot explain ; nor 
yet why abortion should generally happen when the foetus is 
sickly or has been destroyed by syphilis. All we know is, that 
when the deyelopment of the foetus is interrupted, or its life 
becomes extinct, it is a law in the economy of the reproductive 
system of the female for the uterus to be sooner or later excited 
to rid itself of its contents. 

In some instances there is reason to believe that the virus is 
increasing in activity, from the circumstance of the first foetus 
produced not only being born alive, though premature, but con- 
tinuing to live for some time, while several succeeding produc- 
tions are not only stillborn and decomposed, but have been 
expelled at an earlier period of gestation. In other cases again, 
as all these circumstances arp reversed, the disease would appear 
to be exhausting itself. The following case would seem to prove 
that in a twin pregnancy, the virus sometimes progresses very 
differently in each foetus, though both are exposed to the same 
source of contamination. In the summer of 1823, a pupil of 
my class delivered a woman in Rose Street of twin males at the 
full time. The first was dead and much decomposed, while the 
second was living, plump, and apparently healthy. We were 
unable to account for this remarkable difference for some weeks, 
when the secret was revealed by the living infant exhibiting 
imequivocal evidences of syphilis; and shortly thereafter the 
female parent also bepame affected with secondary symptoms. 

I have seen several instances in which a diseased infant con- 
taminated a perfectly healthy nurse. In one of these cases 
where there were ulcers on the child's mouth, the breasts and 
thereafter the whole system of the nurse were affected, and that 
in so short a period of time as to be scarcely credible. On a 
Sunday forenoon this individual received to nurse a twin infant 
born of a parent who had been contaminated by her husband, 
but in whom the complaint was thought to have been completely 
removed by the use of the hydriodate of potass ; and although, 
from the disease having appeared in the child, it was returned 
to its mother on the Thursday following, the nurse was never- 
theless contaminated ; the mammae became affected with copper- 
coloured blotches, and the nipples surrounded by chops and 
small ulcers. 

In infants, at birth, syphilis shows itself under various forms. 



ILLUSTRATIONS OF CONGEXITE SYPHILIS. 13 

Some, as may be gleaned from the foregoing observations, are 
i^ell developed, apparently healthy, and continue so for some 
days or even weeks, when the pelvic limbs suddenly become 
iadistinctly marbled, and if the mischief, as is very apt to hap- 
pen, be not recognised, the child may be carried off after a few 
days in convulsions, without exhibiting any other evidence of 
syphilis. These are most insidious cases, from the indistinct 
evidences of contamination, and from our not probably recognis- 
ing their nature until after an investigation subsequent to the 
infant having been cut off. In a second case the infant is imper- 
fectly developed, presents the appearance of old age in miniature, 
a sallow emaciated aspect, numerous Jarge pustules scattered over 
the surface, ulcers on the lips and angles of the mouth, and 
hoarseness of the voice. The pustules may be flat or prominent, 
suppurate quickly, desiccate without buj^sting, and are soon con- 
verted into dark crusts. Unless this variety be actively and 
promptly attended to, the little patient is very apt to perish. 
A third form in which syphilis shows itself in infants at or soon 
after birth, and which, as far as my observation enables me to 
speak, is the most frequent, is by the genitals being pervaded 
by an extensive excoriation, which attracts little attention until 
scaly copper-coloured blotches are seen on the nates and soles of 
the feet, whence they extend to other points of the pelvic 
extremities, as also to the groins and umbilicus. A great part 
of the surface is at last pervaded by copper or livid coloured 
blotches ; which, on the face and neck are dry, and covered by 
mealy exfoliations ; while on every other region of the body 
they are humid. On the head the hair appears like down, 
though on other parts of the body it be natural. At length the 
external mucous tissues become affected, as the lining of the 
eyelids, nose, and mouth, and of the vagina in female children. 
An ichorous discharge may flow from the nostrils in both sexes, 
and from the vagina in the female ; and in one instance I have 
seen this happen also in a premature male infant, whose mother 
died from syphilis in less than a fortnight after delivery. 

Cases attended with pustules at birth, much affection of the 
mouth, and a considerable degree of hoarseness, require a very 
guarded prognosis. 

It is scarcely necessary to recommend that those children 
should be reared by their parents, to prevent secrets of so deli- 
cate a nature being disclosed, and the disease being communi- 
cated to a hired nurse, who might afterwards institute proceedmgs 



14 ILLUSTRATIONS OF CONOENITE SYPHILIS. 

in a court of law for the recovery of damages. I must express 
my decided disapprobation of all attempts to rear such infants 
artificially, since they are generally so delicate that they are 
almost certain of being lost under such management. And for 
the r^noval of syphilis, I must say that, however suitable the 
water-gruel system may be found in adult subjects, it would be 
most reprehensible to rely on it for the extinction of the virus in 
mere infisuits, or even in older children. There are various pre- 
parations of mercury which may be used with safety and effect ; 
but I have almost invariably preferred calomel. By some of 
our brethren we are advised to limit the exhibition of mercury 
to the nurse; but I am not aware that there are any good 
grounds for this preference, neither am I prepared to say from 
observation that it can be relied on. As, however, when this 
agent is judidously administered, it is perfectly safe, and as it 
must be more satisfactory to subject the child also to its influence, 
I. have invariably acted on this principle. 

The blue mass, hydrargyrum cum creta, and mercurial inunc- 
tions to the soles of the feet, are all safe. I commence with doses 
of a quarter of a grain of calomel, and two grains of creta 
prseparata, once daily for the first ten days ; and thereafter the 
quantity of calomel is progressively increased to a quarter of a 
grain twice each day. The disease disappears rapidly imder the 
influence of this medidne ; but nevertheless it is most difficult 
effectually to eradicate the virus ; wherefore, I have made it a 
rule invariably to continue the medicine for three weeks after 
every vestige of discoloration has vanished. I have seen 
ptyalism only once in a child in consequence of the use of 
mercury. When the nurse feels the child's mouth unusually 
warm, the medicine should be discontinued for a few days, lest 
convulsions might arise from irritation ; a little mild laxative 
should be ordered; and during congenial weather, the Uttle 
patient should be taken into the open air. Should the calomel 
excite diarrhoea, the medicine must be left off, and a dose of the 
tincture of hyoscyamus, with warm bath, ordered at bedtime. I 
have no faith in the exhibition of iodine in such cases ; for in 
every instance in which I have known this medicine employed, 
the disease returned. 

EDINBUBOH, 4 PiCARDV PLACE, Jprtl 1844. 




I>''1H XtANH CASt or IT.HFfiUATlOS uK TI!K AiiiaA 



FATAL HEMORRHAGE FROM PERFORATION CUE* THE AORTA. 15 



Case of Fatal Hemorrhage from Perforation of the Aorta by 
False Teeth impacted in the (Esophagus. Bj James Dunoan, 
M.D., Fellow of the Royal College of Surgeons, L. and E., 
one of the Surgeons to the Royal Infirmary, Edinburgh. 

Calder, aat. 22, Edinburgh, March 9, 1844, had lost 



his two superior anterior incisors when a boy by an injury re- 
ceived when playing at ball. Being a dentist's workman, he 
had, to conceal the loss, made at his spare hours artificial substi- 
tutes which he had worn for the last three months. These were 
intended to be removed at night, and in consequence of this, as 
well as to prevent them from being seen, he had made the gold 
plates, by means of which they were attached to the adjoining 
teeth, as httle projecting as possible, compatible with the retain- 
ing them in position. The consequence was, that their grasp of 
the adjacent teeth was but slight, and they could be displaced 
with ease. His master had repeatedly warned him of the dan- 
ger attending the wearing them during sleep, and recommended 
him always to remove them. He had, however, neglected this 
precaution, and on the 28th February last, he had gone to rest 
with them as usual. In the morning the teeth were amissing ; 
and after a fruitless search for them amongst the bed-clothes, he 
became convinced that he must have swallowed them. He was 
further confirmed in this opinion by the dijficulty in swallowing 
which he experienced, and by the sharp pain wliich he suffered 
when the attempt was made. He was naturally much alarmed 
by the accident, and in consequence applied to Mr Syme for 
assistance. Mr S. passed a probang, and detected a foreign 
body in the oesophagus, considerably below the cricoid cartilage, 
and much beyond the reach of the ordinary forceps used for ex- 
tracting foreign bodies from the gullet. 

Mr S. now recommended his removal to the hospital, and 
when there introduced a probang with threads passed through 
the bulb, the other ends being retained in the hand, trusting that 
if the bulb could be carried beyond the foreign body, it might be 
entangled by them, and thus removed. Nothing, however, was 
detected, and it was believed that it had found its way into the 
stomach, — ^an opinion which was rendered the more probable by 
the fact, that the difficult deglutition was by no means so great 
as previously. So considerable indeed was the relief, that the 
young man requested permission to leave the hospital the same 



16 PATAL HEMOBRHAGB FROM PERFORATION OF THE AORTA. 

evening. It was thought unsafe to comply with this request, 
and he remained in hospital nine days, still suffering from the 
fixed pain already alluded to, and occasionally spitting small quan- 
tities of blood, but without complaining of much difficulty in 
deglutition. The pain was consequently regarded as merely the 
effect of some injury inflicted by the foreign body during its 
passage downwards, and it was thought unadvisable to make any 
farther examination during that period. From some cause or 
other he left the hospital on the evening of the 9th day, and 
returned to his own home. 

Next morning, the 9th of March, I received a hurried call 
from his mother, who had been much alarmed by an occurrence 
which had taken place shortly before I had been sent for. She 
stated that her son had risen from bed, and that in crossing the 
room towards the window, he had become suddenly faint and 
giddy, and had vomited a mouthful of blood. He was immedi- 
ately removed to bed, and complained of a feeUng of great 
weakness. I called upon him as soon as possible, and found 
that during the absence of his mother he had slept a Uttle, but 
still complained of great debihty, and of some shght difficulty in 
breathing. His face was pale, and the skin rather cold, but 
the pulse was of moderately good strength. From his descrip- 
tion of what had taken place, I was led to beUeve that the 
foreign body had been dislodged from its situation, and that it 
was possibly within reach of the forceps, with which I had pro- 
vided myself. I accordingly requested him to sit up by the side 
of his bed, to enable me to make the necessary examination. 
This he did with ease, and without much assistance, expressing 
great anxiety to have something done to relieve him. The act of 
depressing the tongue, to enable me to introduce the forceps, 
produced vomiting, and a mouthful of dark fetid blood was 
discharged. This was immediately followed by another but 
much larger quantity of fluid of the same description, perhaps 
about eight or ten ounces, and the false teeth were heard to rattle 
against the vessel into which it was received. The patient was im- 
mediately aware of this, and his friends were overjoyed at what 
had taken place. Another mouthful of the same fluid was then 
ejected ; an interval of a few seconds elapsed, and then a mouth- 
ful of bright arterial blood was discharged ; a second, and a third 
followed, the lips became livid, the pulse at the wrist ceased, the 
patient gave one or two convulsive sobs, and expired. 

An inspection of the body was readily obtained from the 



BY FALSE TEETH IMPACTED IN THE (ESOPHAGUS. 17 

friends. It was evident from what had taken place, that some 
artery of large size had been perforated, but it was of com'se 
impossible to say, previously to the dissection, what vessel had 
been injured. The following were the appearances met with 
at tho post-mortem examination : — The pharynx, the oesophagus, 
and stomach, along with the carotids, subclavians, and arch of 
the aorta, were removed entire, a Ugature having been previ- 
ously thrown around the duodenum to prevent the escape of the 
blood which had accumulated in the stomach, and so enable 
us to form an estimate of the quantity wliich had been lost. 
The oesophagus, stomach, and duodenum were found distended 
with pretty bright arterial blood. The quantity could not be 
measured ; but in the opinion of those present at the examination. 
Professor Henderson, Mr Shand, Mr Reid, and myself, there 
could not be less than eight or ten pounds. Tl^e pharynx and oeso- 
phagus were laid open by an incision posteriorly, carried as low as 
the cardiac orifice of the stomach. About 4^ inches from the rima 
glottidis there was an ulcerated perforation of the anterior part 
of the oesophagus, of about |ths of an inch in length and three 
lines in breadth, passing obUquely upwards from the right to the 
left side. The edges of the perforation were rounded, and 
there was considerable surrounding injection of the mucous mem- 
brane. By this opening the probe could be readily passed into 
the aorta ; but the latter vessel was not laid open at the time, it 
being thought better to immerse it for a day or two in spirits before 
doing so. On laying open the aorta subsequently, a perforation 
of about the size of a large crowquill was found about half an inch 
below the origin of the left subclavian artery. The opening 
was irregular in form, the edges everted, and at the lower par^ 
there was a pretty firm adherent coagulum. There was httle or 
no vascular injection around this opening; The artery was 
otherwise perfectly healthy. 

I have annexed a sketch of the false teeth, along with another 
showing the point at which the aorta was wounded. The gold 
plate to which the teeth were attached was pretty large, adapted 
to the shape of the palate immediately behind the incisor 
canine and bicuspid teeth on either side, with projections corre- 
sponding to the spaces between these teeth. The two last of these 
projections on both sides were large and pointed, with almost a 
cutting edge. The space between the two terminal projections 
measured one inch and f ths, and the breadth of the plate behind 
the incisors measured fully f ths of an inch. One could scarcely 

c 



18 FATAL HEMOBRHAOS FROM PERFORATION OF THE AORTA 

conceive a more dangerous weapon, or one more likely to be 
followed by fatal consequences, than that I have just described, 
when lodged in the situation in which this one must have re- 
mamed from the time of the accident, in order to have produced 
the extent of ulceration met with on dissection. Its form readily 
explains how it could not be felt, on the second introduction of 
the probang, and oflfered no resistance to the passage of the in- 
strument downwards. From the curve which it describes, and 
from the stretching of the oesophagus between its two terminal 
pomts, ample space must have been left for the passing of the 
instrument; and from the manner in which it must have got 
impacted after the first passmg of the probang, it would present 
superiorly an edge not much exceeding in thickness that of an 
ordinary sheet of writing-paper, so that the bulb would readily 
glide over it without any resistance being met with. 

In every point of view the case was an exceedingly alarming 
one. If the teeth were allowed to remam in the oesophagus, 
they could scarcely fail to induce fatal consequences ; and if they 
passed into the stomach, the result would in all probability have 
been the same, although very dangerous bodies are recorded as 
having passed the whole length of the intestinal canal without 
injury. Even had they been within reach of the forceps and 
grasped by them, or had they been entangled by the threads 
attached to the probang, their removal must have been attended 
with very great danger, and might have proved instantaneously 
fatal from the laceration of the important parts in the vicinity. 
This case also affords an instructive example of one of the many 
modes in which foreign bodies lodged in the oesophagus may 
prove fatal, and inculcates the necessity of removing them as 
early as possible when their removal can be effected. 

Foreign bodies lodged in the oesophagus may lead to fatal conse- 
quences in a variety of ways. When large, the first danger to be 
dreaded is that of suffocation : this may take place instantaneously 
before assistance can be afforded, and many cases are recorded in 
which death has been produced in this manner. Should the foreign 
body not be so large as to induce asphyxia, but remain impacted 
in the oesophagus, various other results may follow. Inflammation 
of the surrounding parts, leading to suppuration, may supervene, 
and the foreign body thus being set free, may either descend 
into the stomach, or may be rejected by the mouth along with 
the purulent matter. Extensive suppuration of the surrounding 
soft parts may on the other hand take place, and may, as has 



BY FALSE TEETH IMPACTED IN THE (ESOPHAGUS. 19 

not unfrequently occurred, lead to fatal consequences. Numer- 
ous cases of this description are recorded, amongst others one by 
Hofer, in which an abscess formed, and gave way into the chest, 
death being the consequence. 

Sir G. Ballingall has kindly communicated to me the case of 
a soldier under his care in IncUa, in which death followed pretty 
extensive gangrene of the surrounding parts. The man, on one 
of the anniversaries of the king's birthday, when in a state of 
intoxication, was eating his curry hurriedly, and in doing so 
swallowed a portion of bone. The probang was passed, but 
nothing could be detected. He remained in the hospital for ten 
days, and then left it, but returned some time afterwards and 
died. On dissection, the bone was found impacted in the gullet, 
and the surrounding soft parts were in a state of gangrene. 

In some few cases, the foreign body, after inducing suppuration 
of the soft parts in the neck, has escaped externally on the spon- 
taneous giving way of the abscess, or has been removed by in- 
cision. One or two are recorded, in which the trachea has been 
perforated by ulceration, and in this manner also the accident 
may lead to a fatal result. In some few instances the foreign 
body has formed a pouch for itself, and has remained there for 
years, and afterwards been ejected by vomiting. One or two 
cases are related in which the foreign body had been expelled 
after the lapse of fourteen or sixteen years. 

Death by hemorrhage, as in the case I have related, is not so 
rare as I was led to beheve, before consulting the Uterature of 
the subject. Many cases in which this has occurred are met with 
in different works, the hemorrhage having followed perforation 
by ulceration of the different large vessels in the vicinity at 
periods more or less distant from the date of the accident. In 
the Dictionnaire de Medecine, 1840, three cases are referred to 
as having terminated in a similar manner to the one I have 
related ; one by Martin, in the case of a soldier who had been 
in the habit of swallowing pieces of money for wagers : these he 
generally passed by stool, but at last he suffered from his folly. 
Fifteen days after one of his exploits, he perished from vomiting 
of blood; and on examination, the coin, which had not been 
passed, was found to have penetrated the aorta, nearly at the 
* same point as in the case I have recorded. — The two other 
cases, the particulars of which I have not been able to 
obtain, are related by Wagret, and Saucerotte. — The carotid 
has been wounded in several instances. One is referred to in 



20 FATAL HEMORRHAGE FROM PERFORATION OF THE AORTA 

the same work as recorded by Dumoustier : I append another 
as related by M. Begin, Surgeon Major at the Val-de-Grace. 
" A soldier, while eating his soup, swallowed a piece of bone, 
which stuck in the oesophagus. Attempts to push it on towards 
the stomach were made, and seemed to be successful. Soft and 
liquid food could now be taken without difficulty, and a probang,. 
upon being introduced, readily reached the stomach. The 
patient seemed to labour under no further inconvenience. He 
left the hospital, but in the course of a month he returned 
again, complaining of a sharp pain in the left side of the neck. 
By the employment of antiphlogistics his ailment was removed, 
and he left the hospital once more. The pain, however, which 
never entirely left him, except for short intervals, became again 
severe ; the patient returned for the third time to the hospital, 
not, indeed, for the particular accident in question, but for a 
gonorrhoea which he had contracted. Every thing seemed to be 
going on well, when he suddenly threw up large quantities of 
blood, perhaps to the amount of seven pounds. The hemor- 
rhage presently ceased, but the next day it returned, and proved 
fatal. On examining the body, there were found in the oesopha- 
gus, about its upper third part, two parallel ulcerations ; that on 
the right side nine lines in breadth, and that on the left twelve. 
Opposite the latter there was an adhesion between the oesopha- 
gufi and the corresponding part of the carotid. In this vessel, 
moreover, erosion had produced a small opening, about a line 
in diameter, which proved to be the source of the hemorrhage." 
Guthrie relates a case, in his work on the arteries, in which 
both carotids were wounded from swallowing pins, a soldier 
having done so in order to get his drill-sergeant into a scrape. 
Another is related by Mr Bell of Barrhead, in the Medical 
Gazette, February 10, 1843, in which the right carotid was 
perforated by a needle, which had been accidentally swallowed. 
The pulmonary artery has been wounded, in one case com- 
municated by M. Bernast of the Toulon Hospital to M. Begin. 
" A young soldier thought he felt, while eating soup, that he 
had swallowed a sharp bone, or a pin ; consequent to which he 
experienced a pungent, lancinating, and occasionally insupport- 
able pain. On entering the hospital, he was treated with an- 
tiphlogistics, but without success ; the pain increased, and kept 
the unfortunate patient in restless misery. Nausea at length 
supervened, and he threw up some ounces of blood. Eventu- 
ally he was seized with convulsions, and he died on the eighth 



BY FALSE TEETH IMPACTED IN THE (ESOPHAGUS. 21 

day. On opening the body, a large quantity of blood was found 
in the chest, especially in the right side. The heart and aorta 
were sound ; but on turning aside the pulmonary artery, there 
was found in front of the CBsophagus a flattened, sharp-pointed 
bone, indented on one of its edges, and^ resembling one of the 
bones of the nose. This had produced an opening in the 
oesophagus, and a corresponding, though very minute one, in 
the pulmonary artery, at the spot where this vessel divides in 
order to be distributed to the lungs. The point of the bone 
was seen in actual contact with the lesion." — From the London 
Med. Gazette, 11th May 1833, p. 175. 

The right subclavian has also been wounded in one case, as 
related by Mr Kirby in the Dublin Hospital Reports, vol. ii. — 
In this case the right subclavian rose from the left side of the 
arch of the aorta and passed to the right behind the oesophagus. 
It is possible that many other cases may be on record, but I have 
not happened to meet with them. 

I have said, that even had the foreign body in this case 
passed into the stomach, death might, and in all probability 
would, have been the consequence. — I might refer to many in- 
stances confirmative of this, in which the patients have per- 
ished from hemorrhage, or from obstruction or perforation of 
the intestines, but I do not consider it necessary to allude 
further to these at present. 

In the accompanying plate, a indicates the situation of the 
perforation ; b par vagum ; c arteria innominata ; e left carotid ; 
g left subclavian ; m a representation on a somewhat diminished 
scale of the false teeth. 



Case of Imperforate Hymen. By A. Webster, M.D., Physi- 
cian to the Dundee Royal Infirmary, &c. 

On the 8th of September 1843, M. C, mill-worker, aged 20 
years and 11 months, consulted me regarding a small and 
hard tumour situated a little below the umbilicus. On inquiry 
I learned that this tumour had only recently attracted attention, 
and that it did not cause much uneasiness, although it was painful 
to the touch. The girl was plump and of a healthy appearance, 
and the manmiae were well developed ; the abdomen was rather 
prominent, and she had never menstruated. For upwards of 



22 CASE OF IMFEBFOBATE HYMEN. 

two years, however, she had been subject to periodical attacks 
of pain about the loins, which generally lasted for days, and 
were accompanied by a sense of weight and bearing down in the 
pelvic region ; and latterly to these symptoms there had been 
added difficult micturition and constipation ; the bowels being 
with difficulty acted upon even by strong purgatives. On ex- 
amination of the external organs of generation they appeared 
normal and fully developed, but, within the labia, there existed a 
strong membrane which completely shut up the entrance to the 
vagina; this membrane was vascular and bulged outwards, as 
do the membranes in child-birth, when they first begin to 
separate the labia. On pressing against it, the feeling communi- 
cated to the finger was that of a bag containing fluid. Having 
thus satisfied myself that the case was one of imperforate hymen, 
I next day, in presence of Mr Ross, house-surgeon to the 
Dundee Boyal Infirmary, made an incision from the pubes to the 
fourchette of about an inch and a half in length, and gave vent 
to upwards of 8 lbs. of a thick brick-coloured fluid. This opera- 
tion afforded great and inmiediate relief, while at the same time 
the abdomen became much diminished in size, and the hard 
tumour below the umbilicus entirely disappeared. I now passed 
my fore-finger into the vagina, which felt as large and relaxed 
as does that of a woman immediately after delivery of a child at 
the full period ; the uterus, however, did not feel enlarged, as 
the OS uteri was as small as in the virgin state. A roll of lint 
was introduced into the vagina to prevent union of the incised 
edges, which was withdrawn and re-inserted repeatedly for 
about a week, till the cure was complete. After this I lost 
sight of my patient, and as she had left her former lodgings, it 
was not without difficulty that I discovered her a few days ago. I 
then learned that about five weeks after the operation she 
menstruated freely, and that she had continued to do so regularly 
till within the last seven weeks ; and this latter suspension she 
accounted for, by informing me that she had been three months 
a married woman, and now considered herself pregnant ; her 
first sexual intercourse was not attended by pain or difficulty. 

Dundee, 20th Feb, 1844. 



CASE OF CONGENITAL ULCERATION AND GANGRENE. 23 

Case of Congenital Ulceration and Gangrene, By T. B. W, 
Potts, M. D., Edinr., M. R. C. S. E., &c. 

In July 1843 my professional assistance was requested by Mrs 
C, a young woman then about the seventh month of her third 
pregnancy, and apparently in the enjoyment of excellent health. 
On the 17th of August, I was summoned to attend her in her 
accouchement ; every thing went on most favourably, and she 
was delivered of a male child after an easy labour of four hours. 
On examining the infant with a view to ascertain its true uterine 
age, I felt assured that it had not attained its full term by at 
least three or four weeks. I also observed something seriously 
wrong with its left foot. After having secured the cord and 
paid the necessary attentions to the mother, this member was 
more minutely examined, and a large ulcer was found on the 
front of the foot, extending from the inferior part of the tibia and 
fibula to the metatarsal bones ; the upper and lower portions of 
the sore were in a gangrenous state ; and the ulceration had pro- 
ceeded so far that the lower ends of the tibia and fibula were 
exposed, as also some of the tarsal bones. A line of demarcation 
commenced to form on the second day after birth, just above the 
upper edge of the sore, but the child sunk on the sixth day. We 
are left in doubt as to the cause of this affection ; but the question 
appears to be, whether was it caused by disease — contamination 
of the system, or by injury, strangulation, or pressure by the 
cord. The mother admitted having contracted syphilis from her 
husband previous to the birth of her two former children, who 
are both alive, and apparently perfectly healthy ; but since that 
period she has had no symptoms of the disease — so far showing, 
that if syphilitic contamination be the cause of the affection 
above detailed, it does not necessarily attack every child born of 
the same parents, even although no steps have been taken to 
eradicate the disease. Had the cord been firmly entwined around 
the hmb, it might by long-continued irritation have produced 
ulceration ; but neither the funis nor the limb exhibited marks of 
pressure having been exerted. I may add, that the quantity of 
liquor amnii was very large indeed ; and had the foetus gone on 
until the full time, it would in all probability have been born 
with one foot only. In consultation with one of my brethren, it 
was deemed prudent not to interfere with the knife, as the child 
appeared very weakly and delicate, and but Uttle hope of benefit 
from an operation could be entertained. 

St Aubixs^ JerseT; March 1844. 



24 BR LYON PLAYFAIR ON SLBBP, 



On the Functions of Oxygen in the Production of Natural Phenomena in the 
Animal Economy. — ^I. Sleep, and some of its concomitant Phenomena, 
Being the Substance of a Lecture delivered at the Royal Institution ofMan^ 
Chester. By Lyon Playfair, Ph. D., F. G. S., &c. &c. 

The researclies of Liebig have lately shown that much information may 
be obtained regarding the processes of life in the animal economy, even 
when these cannot be subjected to direct experiment. Thus he has thrown 
considerable light on the phenomena of motion, by applying to their eluci- 
dation chemical laws, which analogy led him to expect would come into 
operation during the exhibition of these phenomena. But there are many 
other processes, to which he has not devoted attention, but which seem to 
be explicable on the principles which he has so ably established. One of 
these — ^the subject of Sleep— is of great importance in its relations to medi- 
cal practice, and yet very little is known of its cause, or of the chemical 
state of the body during its occurrence. Park, in his able Memoir ** On 
the Causes of Sleep and Dreaming," has pointed out the errors of those 
physiologists who preceded him in investigations on this subject ; but he 
has not succeeded in doing more than establishing that certain physiological 
states of the body offer inducements to sleep, without showing in what 
manner these contribute to the production of a quiescent state of the -mind. 
He considers that the true causes of sleep are, tlie periodical diminution in 
the action of the heart, and simultaneous relaxation of the vessels of the 
brain, by which a slower though fuller circulation of blood through the 
brain is effected. But this merely describes a physiological state of the 
body, without showing in what manner that state favours the quiescence of 
the mind. It therefore does not furnish an explanation of sleep, but merely 
points out the condition of the body which induces the repose of the mind. 
A more accurate definition is therefore desirable, in order that we may 
fully understand the circumstances which predispose to sleep, or occasion 
wakefulness. 

I shall attempt in this paper to show what chemistry seems to point out 
as the probable cause of sleep, and of its concomitant phenomena, more 
with the object of drawing attention to the subject, than with a view to 
insist on the perfect accuracy of the chemical definition. Chemists are too 
apt to fall into the sad error of converting the animal body into a laboratory ; 
and therefore it is the duty of the physiologist to watch their steps nar- 
rowly, and prevent the evils which may arise from this error. On this 
account, I wish the views here given to be looked on with suspicion 
and only accredited so far as they stand in unison with the acknowledged 
experience of medical practice. 

The production of animal heat, according to the chemical view of the 
subject, is due to the union of oxygen with certain constituents of food, or 
with the tissues already formed; The camivora depend wholly on the 
waste of the muscular tissues for the maintenance of the heat of their bodies^ 
for the flesh on which they subsist is destitute of the unazotized organic 
constituents which are employed in supporting the proper temperature of 
the herbivora. Liebig has gone far to prove that the oxidation, or waste of 
tissues in the camivora, takes place only when the vital powers are em- 
ployed in the execution of a movement required by the will — at a time, 
therefore, when they are not engaged in resisting the encroachments of 
chemical affinity, represented in the body by the oxygen contained in 



AND SOME OF ITS CONCOMITANT PHENOMENA. 25 

aiierial blood. He has also shown that the waste of the muscular tissues 
of the herbivora is effected under similar conditions. According to this 
theoty, there cannot be a movement in the body, without a corresponding 
waste (oxygenation) of matter in the organ subjected to motion. The 
circulation of blood in the body, and the constant conversion of venous into 
arterial blood, afibrd an abundant supply of oxygen to replace that expelled 
from the system in the excretions. 

Whilst the animal receives a quantity of food sufficient to restore the 
matter carried off by oxygen, there are exhibited no peculiar phenomena. 
But when it is deprived of food, as in the case of starvation, the changes of 
matter which occur in the system are very characteristic and worthy of 
attention. As the oxygen of the blood does not now meet food, with which 
to unite, it seizes upon the vital tissues themselves, and effects their destruc- 
tion. The sufierer now becomes rapidly emaciated, and the urine is observed 
to contain an excessive quantity of the products which result from a waste 
of the tissues. After this emaciation has proceeded for some time, the sub- 
stance of the brain begins to yield to the destructive action, and, according 
to the rapidity of its waste, excited action or delirious paroxysms ensue. 
Then the heart becomes enfeebled, the blood flows less quickly than it did 
before, the delirium subsides, and the patient dies from exhaustion. The 
phenomena observed in fever, and produced, according to chemists, by the 
entrance into the body of a substance already in a state of oxidation, either 
as a specific contagion, or as malarious matter, are precisely of a similar 
character. The point in its progress, bearing upon our present subject, is 
the increase of force in the involuntary organs, which in time passes over 
to the voluntary organs, and to the brain, producing as in the former case 
delirious paroxysms. 

The great distinction between animal and vegetable life is volition : 
vegetables, not being possessed of volition, are constantly engaged in increas- 
ing their fabric ; and, therefore, when volition ceases in the animal, it is 
aptly said to have a vegetative life, for the vital powers are wholly employed 
in increasing the mass of the body. Sleep is the time when an animal 
becomes assimilated to a vegetable. Physiologists have shown that the 
two most marked points during sleep are diminished respiration and de- 
creased circulation. They are agreed that, towards the evening, or at the 
lapse of a certain number of hours of work, the involuntary organs, the 
heart and lungs, lose their wonted activity, and sufler a periodical diminu- 
tion of action. Blumeubach describes the case of a patient trepanned, in 
whom the brain was observed to sink during sleep and enlarge on waking, 
obviously arising from the circulation being diminished in the former state 
and increased in the latter. The consequence of this diminution is, that 
less oxygen is taken into the system. Hence the proportion of venous 
blood is increased, and the waste caused by arterial blood diminished. The 
skull beuig a close cavity, must contain a larger proportion of venous, if 
there be a diminution of arterial blood in the body. It is the latter alone 
which can cause the waste of the brain, for venous blood has already parted 
with its oxygen to materials met with in its course. 

Matter in a state of inertia can never manifest the existence of a power. 
Its motion alone shows that some power is in operation. If the portion of 
matter used as the organ of manifestation be placed in such a condition as to 
render that manifestation impossible, there is no evidence to the external 
world that power was exerted. It has been perfectly demonstrated, that 
every manifestation of power in the voluntary organs is accompanied by a 



26 DR LYON PLAYFAIR ON SLEEP, 

change in the matter of which they consist. The changed matter being 
nowAinfit for vital structures is separated from the body. MQller and all 
other eminent physiologists are of opinion that the same change takes place 
in the brain, the organ of the mind. In fact, the contrary opinion involves 
such violation of analogy, that its adoption, unless founded on the strongest 
grounds, is inadmissible. We look upon a spot attentively ; it gradually 
waxes dimmer, until it finally disappears. We think upon a particular 
subject ; in time our thoughts are less clear, soon they become strangely 
confused, and we are obliged to give up the attempt at concentration, by 
thinking on a subject quite different from that which first engaged our 
thoughts. This of course implies that the organs of manifestation have be- 
come in part destroyed, and that the mind cannot manifest itself to the 
world, until the impau*ed organs have attained their proper integrity ; for 
it cannot be conceived that the mind, disconnected with matter, could suffer 
exhaustion. This involves, it is true, the idea that different parts of the 
brain are employed in different manifestations, but we know that as fiir as 
sensation and intellect are concerned, this is the case, and probability indi- 
cates a still more minute division. If, therefore, the brain suffer changes, as 
do the other organs of the body by their exercise, there is as much necessity 
for repose in the action of the brain, as there is for a vegetative state of 
existence to reinstate in their full integrity the organs of volition. Hence 
the necessity for that quiescent state of the mind known as sleep, when its 
manifestations cease. The waste of cerebral substance could only have 
been occasioned by oxygen, which is the only ultimate cause of waste, as 
far as we are aware, in the animal economy. A deficiency in its supply 
would therefore retai'd waste, and allow vitality to remodel its impaired 
structures. 

Such then is the state into which the body is thrown by the periodical 
diminution in the action of the heart and lungs. The less rapidly that the 
heart beats, the less rapidly can the blood be aerated, and the oxygen- 
bearing fluid can be supplied to the brain. The slower that the lungs act, 
the slower must oxygen enter the system to supply the diminished circula- 
tion. And as the brain in sleep is not in a state in which it can change, 
from a deficiency in the supply of oxygen, the consequence is (if it be ad- 
mitted that the manifestation of thought and sensation is accompanied by 
changes in the material substance of the brain), that the manifestations 
of the mind are prevented, and it becomes no longer apparent to the 
external world. 

This, then, is Sleep. But if the theory be correct, it must be able to 
explain the various circumstances which occasion or act as predisposing 
causes to the production of this state, and if it fail in the explanation of any 
of these, then is the theory imperfect ; but if it explain more of them than 
the other theories usually received, such as those of CuUen, Blumenbach, 
Park, and others, it deserves to be considered as a nearer approximation to 
the truth, and the cases which it fails to comprehend may be included as 
our knowledge advances. 

The first point demanding consideration is, how it happens that a recum- 
bent posture is favourable to sleep. Park justly ascribes this to the dimin- 
ished pressure of the blood on the heart* The weight of the column of blood 
from the head to the heart, estimated by Hales as equal in force to five 
pounds, is removed, and thus its distending force is diminished. The heart 
now relaxes, and the blood therefore is sent less slowly through the system. 
Having, by the horizontal posture assuihed, acquired a retarded flow, the 



AND SOME OF ITS CONCOMITANT PHENOMENA. 27 

blood now comes less rapidly in contact with the oi^gans of respirationy on 
which the same posture has produced a diminished action, and thus the 
quantity of arterial blood in the body becomes diminished. Though, 
therefore, all the vessels in the brain remain as fiill as they did before, yet, 
by the deficient supply of oxygen, or, in other words, of futerial blood, and 
by the retarded circulation of that which does exist in the cavity of the 
skull, the causes of waste are diminished, and therefore, according to the 
theory, sleep is produced. For the same reason, sleep ensues when the 
aorta of an animal is tied, or when arterial blood is removed in lai*ge quan- 
tity from the body by excessive bleeding. Bichat has shown that when 
venous blood is withdrawn from a vein and projected into an artery, sleep 
ensues^ amounting to asphyxia, or even to death. The later researches of 
Dr Kay, now Dr Kay Shuttleworth, have proved that part of the results 
obtained by Bichat might have been due to an increased pressure on the 
brain ; but Dr Kay's observations, while they modify, do not set aside the 
experiments of the former physiologist. 

Any thing which removes the oxygen from the blood will in the same 
manner cause sleep. This is particularly apparent in the debauch of a 
drunkard. The drunkard takes alcoholic liquors with the production of 
two opposite effects. At first his heart beats rapidly, the blood flows more 
quickly, and he enters into that stage of fever which I described at the out- 
set of the paper, in which the rapidity of circulation causes such an enor- 
mous supply of oxygen to the brain, that its substance wastes so rapidly as 
to become unfitted for the seat of the intellect, and delirium ensues. But 
even while this delirium is at its height, the vapour of the alcohol is pene- 
trating by diffusion every part of hb body. Its hydrogen and its carbon 
are converting arterial blood into venous by depriving the former of oxygen, 
which is its essential characteristic. The delirium now subsides ; but the 
alcohol carries on its work of depriving the blood of oxygen, and the latter 
now not reaching the brain in quantity as it did before, prevents change in 
its substance, and the drunkard falls down in deep stupor or sleep. To re- 
store him from this state, we withdraw the combustible fluid from the sto- 
mach by means of the stomach-pump, and by ammonia and other stimulants 
endeavour to excite respiration and circulation, in order that the alcohol 
may be more i^edily consumed. 

The action of alcohol diflers from that of opium or narcotics ; because 
the permanent eflect of the latter, whatever the first transitory effect may 
be, is to diminish the action of the heart and lungs, and therefore the sleep 
thus occasioned is brought about by causes exactly similar to those which 
in the natural state of health produce ordinary sleep. 

The tendency to sleep in different animals is in inverse proportion to the 
amount of oxygen consumed by them, and to the amount of carbonic acid 
produced. Thus, reptiles and the naked amphibia produce, relative to their 
weight, according to the experiments of MiiUer, one-tenth the amount of 
carbonic acid evolved by mammalia, and one-nineteenth that of birds. We 
have no numbers to express the tendency to sleep of these animals, but it 
IS known that reptiles are peculiarly liable to be in a state of torpor or 
sleep, while birds are, on the contrary, wakeful animab. A reptile, such as 
a frog, will exist in a state of torpor for twelve hours in an atmosphere of 
pure hydrogen gas, while birds die in the same number of seconds with the 
ordinary symptoms of asphyxia. Hydrogen gas, when respired with air, 
gives a tendency to sleep, as shown by the experiments of Allan and Pepys, 
probably owing to the conversion of arterial into venous blood, as in the 



28 DR LYON PLAYFAIR ON SLEEP, 

case of alcohol. The same circumstance of a diminished supply of oxygen 
to the hlood, which induces sleep in reptiles, acts also in different mamma- 
lia in the promotion of this state, according to the relatiye size of their- 
lungs. The same circumstance seems to operate in a like way with differ- 
ent men. 

The only explanation which I have seen of the tendency to sleep after a 
heavy and excessive dinner is that first promulgated, I helieve, hy Macnish, 
who ascrihes it to the drafting away of a large amount of sensorial or nervous, 
power from the hrain to complete the digestion of the excess of food in the 
stomach. This implies the necessity for considering the first act of digestion 
as an act of vitality, of which, to say the least, there are great douhts. But 
the drafting of sensorial power, that is, as I take it, of power connected 
with the operation of the mind — for, if not, its removal could not favour 
the quiescence of the latter — is a mode of explanation which must be con- 
sidered entirely hypothetical. I am not aware that an inducement to sleep 
is in general experienced when a small quantity of an indigestible food is 
taken into the stomach, and yet this ought to be the case according to the 
view of Macnish. The tendency to sleep is occasioned when the stomach is* 
too much distended by an excess of food (or if it do occur with a small 
quantity of an indigestible aliment, then there is an excessive flow of arte- 
rial blood to the stomach to assist in the more rapid oxidation of its coat, 
which the German chemists have dignified as the formation of a peculiar 
substance termed pepsin). The consequence of this distention is, that the 
diaphragm which separates the intestines from the heart and lungs is pushed 
upwards against the latter, encroaching upon the space which ought to 
be occupied by them, thus preventing their free play, or, in other words, 
depriving the blood of its proper supply of oxygen, and therefore producing 
sleep. A person subject to sleep after dinner experiences a sensation of 
cold, obviously arising from the diminished oxidation in his body. If this 
cold continue, sleep is prevented ; because it excites — as cold generally does 
—the respiratory organs to greater activity, and this activity acts as an an- 
tagonist to sleep, or in &ct neutralizes the effects arising from the pressure 
of the diaphi-agm against the lungs. Hence it is that such persons draw 
their seats towards the fire. The warmth of the fire prevents the increased 
action of the lungs by preventing a diminution in the temperature of thei 
body, cmd therefore the lungs are not excited to increased action, and sleep 
ensues. Hence, also, a gentle walk after dinner removes the tendency by 
accelerating the play of the lungs, which now, by their increased action, 
introduce sufficient oxygen into the system to prevent sleep. It is alsa 
possible, as has been suggested to me by Mr Noble, that the increased flow 
of arterial blood to the stomach after a heavy meal may cause a tendency 
to sleep by withdrawing a corresponding quantity from the brain. The; 
effect occasioned by the pressure of the diaphragm on the lungs until the 
distention has ceased, is analogous to the more permanent effects produced 
in very fat individuals. It is well known that very fat people are peculiarly 
prone to sleep. The fat accumulates around the viscera, pushes up tha 
diaphragm, and lodging around the heart and edges of the lung^ the lattet 
by all these causes are compelled to play in smaller space, and soon becomo 
permanently contracted. Hence, any cause which occasions diminished re* 
spiration in such an individual will cause him to fall asleep, by diminishing 
further the supply of oxygen to the system. The mere diminution in the 
action of the lungs produced by sitting often occasions sleep in such persons. 
In their case, the further protrusion of the diaphragm cdter meals almost 



AND SOME OF ITS CONCOMITANT PHENOMENA. 29 

uiYariably produces sleep. This is more marked in animals fattened for 
the butcher. Pigs in the last stage of fattening exhibit this disposition in a 
marked manner. After distending their stomachs with food, they give a 
few ineffectual attempts at an active respiration, and £Edl into deep sleep. 
The cause is the same as that first stated, namely, the pressure of the dia- 
phragm against the lungs ; this prevents a proper supply of oxygen from 
entering the system. Macnish was not wrong in his observation that the 
sensorial power became diminished in the brain after a heavy dinner ; but 
he mistook the effect for the cause, when he attributed the tendency to sleep 
to the abstraction of this power. The diminution of the quantity of arterial 
blood in the cavity of the skull appears to be the true cause of sleep in 
this case ; and the decrease of sensorial power is a consequence, but not the 
cause, of the sleep. It cannot be considered that the absence of a disposition 
to sleep in some kinds of dropsy, in which the diaphragm is pushed against 
the lungs, forms a decided objection to the view given of the tendency to 
sleep after dinner ; because the contraction of the lungs being gradual, na- 
ture suits itself to the circumstances by exciting a more rapid respiration. 
Besides, the results occurring in the diseased state ought not to be considered 
strictly parallel to those we would expect if the body were in health. 

Perhaps I might venture to throw out this view as explanatory of the 
winter sleep of hybematmg animals. In summer these animals accumu- 
late fat in their bodies ; probably from the very fact of the smallness of 
their lungs, which prevents the entrance of a sufficient supply of oxygen 
to convert the unazotized portion of their food into carbonic acid and* 
water. This fat, accumulating around the caul and loins, pushes forward 
the diaphragm against the lungs. The fat also gathers round the edges of 
the heart and lungs, and still further diminishes the space in which the 
latter ought to play. Thus respiration is greatly retarded, in consequence 
of which the animal falls asleep. This explanation accords with the in-' 
teresting experiments of Saissy, who has shown that hybemating animals 
decompose most air when they are in a state of greatest activity, that they 
respire less during autumn as their fat accumulates, and that the respira- 
tion becomes extremely feeble at the commencement of their winter sleep, 
and ceases altogether when that sleep becomes profound. Spallanzani 
has confirmed this fact, showing that there must be a cutaneous respiration, 
for a small amount of carbonic acid is evolved, although the lungs cease- 
to act. During the long'-continued sleep of the hybemating animals, the 
longs play slowly ; in fact, several minutes often elapse between each 
respiration, and the diminished state of oxidation is proved by the reduced 
temperature of their bodies, which is generally not higher than four 
degrees above that of the surrounding medium. In this state they have been 
aptly compared to lamps slowly burning, their fat being the oil, and the 
lungs the wick of the lamp. It is true that cold is favourable to the- 
production of hybernation, and this is not in opposition to the theory ; 
but Berthold has shown that hybernation takes *place in a warm as well as 
in a cold atmosphere. If our view be correct, very fat animals should- 
show a similar disposition to sleep, and it is knovm that a pig in its last 
stage of fattening is rarely awake. Instances have occurred, in which 
pigs, being placed in a favourable condition, have actually proved their 
capability of being in a state of hybernation. Thus Martell describes the 
case of a fat pig overwhelmed with a slip of earth, which lived 160 days 
without food, and was found to have diminished in weight in that time^ 
more than 120 Ibs.^ an instance quite analogous to the state of hybernation/ 



30 DR LYON PLAYFAIR ON SLEEP, 

It is well known that intense cold is a powerful inducement to sleep. 
This effect is partly mechanical. The vessels containing blood become con- 
tracted ; the blood itself becomes more dense, and flows more sluggishly ; 
and consequently the brain, from the operation of both these causes, is less 
freely supplied with arterial blood. The theory therefore explains the result. 
This is the case only with extreme cold, for a slightly reduced tempera- 
ture, instead of promoting, often retards deep. But here also the theory 
is true to itself, for slight cold is known to increase the rapidity of res- 
piration, and therefore causes an increased supply of oxygen to the 
system. Slight cold cannot act in this way so easily in the case of 
hybemating animals as in others, because the accumulation of fiit, and 
enlargement of the glands in the chest and neck, press upon the res- 
piratory nerves and prevent their proper action. 

If, then, it be true, that before the mind can manifest itself to the ex- 
ternal world, its organ, the brain, must be in the position to unite with 
oxygen, any thing which tends to withdraw it from that position must 
cause an impairment of the faculties, even if the cause do not operate 
with sufficient intensity to produce sleep. This is very apparent in the 
cold stage of ague, when the blood circulates slowly through the body. 
In fever, on the other hand, when the blood rushes in a torrent through the 
system, the mind becomes acutely sensible to every perception. In fever 
also we find little disposition to sleep, and when this does occur, it is 
restless and disordered, accompanied by troubled dreams. The chemistry 
of this disease affords us an instructive lesson with regard to phenomena 
resulting in the case of health. There are two states into which organic 
matter passes; — decay, being the change which ensues when a large 
supply of oxygen is present ; putrefaction, when that supply is 
deficient. During the waking state in fever, decay or eremacausis pro- 
ceeds rapidly, and delirium, the consequence of this state, appears when 
the heart beats quickly and the lungs play strongly ; in other words, when 
the greatest supply of arterial blood is sent through the system. But dur- 
ing night, when the oxygen-bearing blood is decreased in quantity by dimin- 
ished respiration — when oxygen is therefore not present in quantity sufficient 
to combine with the changing matter — then it passes over into putrefac- 
tion, indicated by the petechie which then appear. This chemical view 
of fever, either as exhibited in fevers of the typhoid type, or those occur- 
ring in malignant forms of disease, is not unimpoHant. If the appearance 
of petechiffi during sleep be, as I suppose, an indication that the body has 
passed over from the chemical state of eremacausis to that of putrefaction, 
from a deficiency in tlie supply of oxygen, then the means for the pre- 
vention of these states are very different, and the practice in the treatment 
might be made to suit the. periodicity of the return. I throw this out as 
a mere suggestion for further inquiry. But there are numerous points in 
support of this view. It is only in the absence of increased action that 
we observe the ammoniacal* nature of the excretions, or the pe^iuliar odour 
of the breath which indicates a state of change, the very reverse of that of 
eremacausis. In this state, even on the old system of treatment, bleeding 
was not resorted to, but, on the contrary, stimulants were employed to cause 
increased circulation ; for experience pointed out that the change thus begun 
is that which continues when vitality has left the body. 

This case affords a clue not only to the explanation of chronic wakeful- 
ness, but also to wakefulness under ordinary circumstances. Some organic 
matter, in a state of decay, has entered the body, and has thrown the blood 



AND SOME OF ITS CONCOMITANT PHENOMENA. 31 

into a sinular state of change. To prevent any dispute as to tlie kind of 
matter, let us take the case of sympathetic fever, or that of cynanche ma- 
ligna. A patient enters the hospital with a fractured bone ; — the case goes 
on favourably, — ^nothing is at first observed but local irritation ; — ^then it may 
assume a malignant form, — ^pus, obviously by its odour in a state of change, 
is observed to collect ; — ^Uien some of this is absorbed into the blood (for 
Gulliver states that he has found it there), and communicates to that fluid 
the same state of change ; — then fever, called sympathetic, ensues ; but if 
it be " sympathy,*' it is sympathy exerted by one matter upon another, as 
a decaying orange excites decay in a fresh orange. This fever, be it ob- 
served, does not arise usually when an abscess is unbroken. It is generally 
excited when the pus has come in contact with air, and has united with 
oxygen. We try to prevent this union by means of poultices, these poul- 
tices being made of materials which will of themselves unite with oxygen, 
and thus prevent it acting on the pus. Occasionally poultices are used 
made of yeast and flour, as in the cataplasma fermenti of the London Pharma- 
copeia, the object being to surround the pus with an atmosphere of carbonic 
acid, and thus prevent the access of oxygen. The most favourite poultice in 
use is that made with linseed, which from its oil and mucilage possesses a 
powerful affinity for oxygen. The state of change, being once excited, goes 
on, and cannot be arrested without vigorous measures ; sometimes not at all 
until death ensues, from the combined effects of decay and putrefaction 
following each other as the oxygen is sufficient or deficient. But the point 
to be observed is this, that the change in the blood once begun is with diffi- 
culty arrested ; the disposition to oxygenize is communicated, and if there 
be oxygen sufficient, matter will be oxidized. Then, to apply this to our 
subject, the brain becomes excited by intense thought, by the exercise of 
imagination, by exciting scenes of amusement, or by whatever cause it may 
be. The mind, being called into full exercise, must in its manifestations 
cause a change of matter in the organ in which it resides. But in this case 
the change of matter is excessive, and the tendency to oxidation is commu- 
nicated to the part of the brain contiguous to that in a state of change. 
This also becomes oxidized, and the cerebral substance does not get into 
that state which favours the quiescent state of the mind known as sleep. 
The student, after severe and exciting study, is familiar with this state of 
wakefoluess. If his studies have been such as to demand the exercise of 
his reason, on retiring to rest he endeavours to force his attention into 
subjects the reverse of the former, generally those of imagination. In other 
words, he endeavours to withdraw the mind from manifesting itself through 
that portion of matter which is thrown into a state of change, and by so 
doing it gradually resumes a state of tranquillity, and sleep then ensues. 
But if, by excessive or diseased action, such as in insanity^ the inflamed (oxy- 
genizing) matter cannot be made to yield its tendency to change, then 
chronic wakefulness ensues, so often seen in the case of the insane. To re- 
duce this state, we endeavour to extinguish the eremacausis, by lowering 
the temperature either by cold ablution or by ice, or by administering 
opium to diminish respiration and circulation. As soon as the change is 
arrested in the substance of the brain (what physicians call *^ inflamma- 
tion," which chemists interpret *^ union with oxygen"), the brain is placed 
in a state unfit for being the organ of manifestation, and sleep ensues. The 
wakefulness of patients afflicted with delirium tremens is obviously con- 
nected with the amount of arterial blood and consequent inflammation and 
oxygenation of the brain, and as disease is merely a disturbance of the equi- 



32 DR LYON PLAYFAIR OX SLEEP, 

libtium in the causes of waste and those of supply, any magnified exhibition 
•of a phenomenon occurring in disease must have its reduced analogue in the 
ordinary state of health. Wakefulness is that analogue, being a tendency 
. to excessive change in particular parts of the bredn, induced, it is true, not 
primarily by the change, but by the activity of the mind itself requiring 
that chuige to aid in its manifestation. Follow the analogy, and we come 
to dreaming, which, apart from its metaphysical aspect, is a physiological 
phenomenon, so &r as concerns the state of the matter of the brain during 
its occurrence. In fever and insanity we attempt to reduce the keen per- 
ceptions or delirium by the exhibition of remedies calculated to diminish 
the waste of matter in the brain. Blood is sometimes withdrawn from the 
system for the purpose of diminishing the number of the carriers of oxygen. 
Narcotics are administered in order to decrease the number of respirations, 
and to diminish circulation. In extreme cases, large doses of brandy or 
other alcoholic liquors are exhibited, for the combined purpose of depriving 
the blood of oxygen and of arresting putrefaction. 

By all these acts it is admitted that the excessive waste or oxygenation 
of the substance of the brain renders it unfitted for the proper seat of the 
mind. It is admitted that the rapid change of matter prevents the brain 
attaining that state which favours the quiescence of the mind. How it does 
so we do not know, and perhaps never shall. But these are established 
facts, the foundation of medical and physiological practice, and therefore 
cannot be denied. And if this be admitted with regard to the whole sur- 
face of the brain, may it not be so of a part ! Combe tells us of a patient 
who was afflicted with an imnatural increase of a feeling of the mind, 
but that by applying ice to a particular part of the head which was 
inflamed, the feeling subsided to its natural tone. Dreaming, then, might 
be considered (this I throw out as a mere speculation) to be a dis- 
turbance between the causes of waste and of supply in a particular part 
of the brain. I mean that if, to use the language of phrenologists, with- 
out necessarily assenting to their doctrines, the oi^n of Wonder, from 
some cause or another, be thrown into a state of oxidation during sleep, 
that part of the brain would be thrown out of the condition which iavours 
the quiescent state of the mind ; Wonder would therefore manifest itself to 
the external world without being guided by the reasoning powers or 
judgment, which are in quiescence or sleep. Thus it would revel in all 
the absurd phantasies to which that feeling of the mind gives rise. I have 
selected this phrenological organ as a mere example of my meaning, with- 
out wishing to insist upon the division of organs as a necessary part of the 
speculation. If those parts of the brain used as the organs of manifestation 
for judgment were brought into play at the same time as Wonder, the 
dream would be more coherent, and, as soon as the change took place to 
such an extent as to throw the brain into that state which did not favour 
the quiescence of the mind, then waking would ensue. Hence, according 
to this speculation, dreaming is a state of wakefulness of feelings of the 
mind manifested through particular parts of the brain, while other feelings 
. of the mind, manifested through other parts of the brain, are still asleep, 
and thereforo not in a condition, by comparison and reflection, to modify 
those awake. It is probable that during dreaming there is more ar- 
terialized blood in the cavity of the head than during sleep without dreaming, 
a circumstance indicated by the red flushed appearance of the face during 
dreams. The speculation is also supported by the class of persons subject 
to dreaming. A phl^;matic person, whose heart beats slowly and whose 



AND SOME OF ITS CONCOMITANT PHENOMENA. 33 

loDgs play slowly, rarely dreams. A fat person, with a diaphragm well 
poshed up against his lungs, rarely dreams. But the greatest dreamer 
is the man of nervous temperament, whose heart and lungs do not 
play with all the sted&stness of the pendulum of a clock, but by causes 
yet unexplained are fitful in their action. For the same reason, in fever, 
the quickly circulating blood, sometimes propelled more rapidly than at 
others, is apt to cause this state of wakefulness in particular parts of the 
brain, by thro¥ring them into a state such as does not favour the quiescence 
of the mind. However, this is a subject which is thrown out as a mere 
speculation for consideration. 

It may be objected to the view of sleep here given, that if it were owing 
to a diminislied state of oxidation in the brain, the respiration of pure oxygen 
ought to retard sleep, whereas, on the contrary, it is observed to render 
the animal exposed to it comatose, and death ensues after the animal has 
remained for some time in a state of deep stupor. Yet both the blood in the 
veins and arteries was found by Broughton to be very florid, and every 
thing indicates a high state of oxidation. Christison and other toxicologists 
ascribe the death to an increased oxidation or hyperarterialization of the 
hlood. The phenomena, therefore, seem in direct opposition to our theory 
of sleep. But let us consider the case closely. Arterial blood differs from 
venous in the state of oxidation of its iron. The peroxide of iron parts 
with its oxygen to the tissues, and converts the matter acted upon into car- 
bonic acid and water. The carbonic acid unites with the protoxide of iron, 
and is carried as carbonate of iron by the venous blood to the lungs, where 
it becomes oxidized, and the cai'bonic acid evolved ; for this gas is incapable 
of uniting with peroxide of iron. Now, when an animal breathes oxygen, 
even the venous blood is arterialized, or, in otlier words, there is no pro- 
toxide of iron left in the system. But, owing to the excess of oxygen gas, 
there must be a rapid waste of the tissues, and the formation of a large * 
quantity of carbonic acid gas, which has now no iron in a state to carry it 
to the lungs. It therefore accumulates in the system, and the animal be- 
comes conoatose and dies, not on account of oocygeriy but of carbonic acid 
which has no means of escape. It has been remarked, that there is com- 
paratively little carbonic acid evolved in poisoning by oxygen, for the at- 
mosphere in which the animal dies causes a blown-out taper to burst into 
flame. The heart after the death of the animal is found to beat rapidly, 
and shows the excited state into which the body was tlirown by oxygen, 
until the accumulating carbonic acid produced the peculiar effects for which 
it is remarkable. Thus, this simple explanation, while it vindicates the truth 
of the theory, affords an explanation of the cause of poisoning by oxygen, 
which toxicologists have always considered as most incomprehensible and 
singular. The effects of nitrous oxide on the system are very similar to 
those of oxygen, and are obviously due to the same cause. Broughton found 
that even the venous blood* had become arterialized when an animal was 
made to respire this gas. 

The attentive study of the peculiar condition of matter in the various 
states in which the mind manifests itself, or remains unmanifested to the 
external world, is of great importance in the treatment of disease. To take 
the case of apoplexy and its allied diseases. I do not allude to apoplexy occa- 
sioned by the rupture of an apoplectic sac, but that form in which it arises from 
the turgid state of blood-vessels in the brain, or in the more rare form of what 
is termed '* simple apoplexy" by Dr Abercrombie. The state in which the 
brain is placed in this disease seems to be merely an increased state of the 



34 DR LYON PLAYFAIR ON SLEEP. 

condition in ordinary sleep. The congestion or turgid state of the venous 
vessels necessarily implies a diminished amount of blood in the arteries ; 
for the skull, being a close cavity, must always contain the same amount 
of fluid ; and on this account, if the quantity of venous blood be increased, 
that of arterial blood must be diminished. Hence, although the use of the 
lancet may awaken the patient from deep stupor, by removing the deoxi- 
dized blood which may have accumulated in the brain by the lesion of a 
vessel or by some irregularity in the action of the heart, yet it becomes a 
question, whether the removal of blood, by diminishing the number of 
c-arriers of oxygen to the brain, may not cause a tendency to relapse when 
the temporary obstruction shall have been removed. All I mean by this 
is, that if we admit the cause of sleep to be a diminished supply of oxygen 
to the brain, we must admit certain forms of disease, such as congestive 
apoplexy, syncope, perhaps even catalepsy, to be due to the increased ope- 
ration of the same cause, — a circumstance attested by the diminished tem- 
perature of the body which results in this class of diseases ; if, then, we 
know the effects to be due to a want of oxygenation of .the substance of the 
brain, we are in a position more completely to regulate our practice in the 
ti*eatment of such diseases. So, also, in the treatment of wakefulness, dream- 
ing, restlessness, &c., for which the physician is so often called upon to pre- 
scribe a remedy, the knowledge of the state of the brain in the state of 
waking and of sleep, may point out the way to throw it into the state which 
fevours the activity or quiescence of the mind. Hence an accurate defini- 
tion of these states is not unimportant in a practical point of view. 

It does not necessarily impair the accuracy of such a definition, that many 
assumptions are taken for granted to explain one part of the phenomenon. 
When we see a wheel revolved by the ascent and descent of a piston-rod, 
our explanation of the means by w hich a perpendicular is converted into a 
rotatory motion is not rendered valueless because we do not trace it to the 
means by which the force is generated. We have a right to assume the 
existence of the necessary force, and from this point alone attempt an ex- 
planation. So, also, when I say that the effect of a diminution in the play 
of the respiratory organs induces sleep, as in the case of intense cold, or that 
their accelerated action retards sleep, as when the temperature is only 
slightly depressed ; mj conclusion may be perfectly correct, without my 
being called upon to prove the cause of the diminution in the action in the 
one case, or its increase in the other, because my attention is confined only 
to one part of the phenomenon. So, also, if I say that syncope id due to a 
diminished quantity of arterial blood in the brain, I may be correct as to 
the proximate causey without being obliged to show by what means the 
conducting power of the nerves leading to the involuntary organs has become 
so impaired as to cause the temporary obstruction of these organs. In de- 
scribing the chemical state of the body, and the effects produced by this 
state, the duty of the chemist is only to consider the proximate cause of its 
production, while the physiologist ought to explain the ultimate causes 
which predispose the body to enter into that state. I have attempted to 
explain in certain cases one part of the phenomenon, not for the purpose of 
giving idle play to fancy, but with the hope that these speculations, if they 
do not of themselves represent the truth, may lead other persons to the 
coiisideration of the same subject. 



ORGANIC DISEASES OF THE UTERUS. 35 



paet il— reviews. 



A Practical Treatise on. Organic Diseases of the Uterus. By 
John C. H. Lever, M. D., &c. 8vo, pp. 228. London, 1843, 
Longman & Co. 

The industry with which Midwifery, in all its departments, has 
of late years been cultivated in this country, has placed this most 
uscM branch of our profession on a footing fully equal with, and 
indeed superior in soundness of principle to, the position which it 
occupies on the Continent. Our periodical literature teems with 
useful physiological, pathological, or practical observations, and 
there is no lack of valuable essays on particular subjects, and* 
systems of great excellence. 

We do not hesitate to state, that the volume before us, though 
it does not contain much that is very novel, substantiates, how- 
ever, by statistics, and an ample collection of well-selected facts, 
our previous knowledge of obscure diseases, of which, in this 
impretending treatise, we have in many instances a graphic, 
account, devoid of those numerous but useless generalities and 
tiresome speculations by which we are too frequently nauseated 
while perusing similar works by our continental brethren. Dr 
Lever is placed in an enviable position for acquiring a sound 
pathological knowledge of female diseases ; and we must do him 
the justice to say, that he seems to be armed with zeal and indus- 
try — qualifications which are indispensable for a man who enters 
the field which he has undertaken to explore. 

The subjects embraced by this volume are classed under three 
heads, viz. Part First, Acute and Chronic Inflammation of the 
Uterus ; Part Second, Specific Diseases ; and Part Third, Ma- 
lignant Diseases. We extract the following account by the author 
of the relative proportion of functional to organic disease. 

^ Of 2582 who applied for relief, there were 1660 cases of functional to 
922 of oiganic disease. In 905 cases of functional derangementy there were 
with Leucorrhoea 310, Menorrhagia 125, Chlorosis 145, Hysteria 68, Dys- 
menorrhoea 27, Irritable Uterus 19, Vicarious Menstruation 7, Epilepsy 6, 
Chorea 2, Hemiplegia 2, Amaurosis 1. In 483 females with organic dis- 
eases, there were affected with Inflammation of the Os and Cervix 17I9 
Carcinoma Uteri 104, Hard Tumour of the Uterus 69, Fungoid Disease 



36 ORGANIC DISEASES OF THff UTERUS. 

45, Chronic Inflammation of the Uterus 44, Induration of the Os and Cer- 
vix 28, Polypus 12, Chancre of the Os Uteri 4, Miliary Disease of the Os 
and Cervix 3, Hysteritis 2, Cauliflower Excrescence 1.** P. 2. 

To his own, Dr Lever adds the experience of resident practi- 
tioners abroad, regarding the comparative frequency of the dis- 
eases under consideration, which, independently of the valuable 
matter furnished by himself, will recommend his performance to 
his professional brethren as a useful book of reference. Thus, 

** At CorfUy one in 50 suffers from dysmenorrhoea ; carcinoma uteri hap- 
pens in the same proportion ; while all who are affected with the latter 
have had syphilis in early life* At Jamaica^ 20 out of every 100 adult white 
females are subject to functional derangement ; 10 per cent, to carcinoma, all 
of whom had painful or suppressed menstruation previously : diseases of the 
uterus, whether functional or organic, are very rare amongst the blacks. At 
Quebec, among the French Canadian women, carcinoma uteri is said to occur 
in the proportion of 3 in 50, and in females who had previously been affected 
with amenorrhoea or dysmenorrhcea. The same observations are said to be 
^ applicable to Indians, more especially those located in the vicinity of large 
towns. Among the British Canadians the propoi*tion is stated to be the 
same, and that the subjects had always previously suffered from dysmen- 
orrhoea. In convents the occurrence of functional and organic disease is 
more frequent ; 10 women in every 50 are said to suffer from organic lesion. 
At Halifax^ one woman in 40 is said to be affected with organic disease, and 
generally those who had been subject to scanty menstruation. During 
several yeare* experience at Belle Isle, Upper Canada, only one case of car- 
cinoma uteri had been met with, and this too in a woman who had suffered 
from deficient and painful menstruation. In Montreal^ 8 in 50 are said to be 
affected with functional derangement ; 2 in 50 with oi^nic disease," P. 3. 

From the foregoing observations it is evident that dysmenor- 
rhcea frequently predisposes to organic disease of the uterus, 
while it must also be well known to those engaged in practice 
that the same causes which often in early life give rise to painful 
menstruation, as the depressing passions, are likewise, at a more 
advanced age, frequently concerned in producing carcinoma uteri. 

Our author next proceeds to inquire whether married or single 
women are most disposed to organic changes, and a very little 
consideration of the subject would naturally lead us to infer that 
the former are far more so than the latter, owing to their greater 
liability to excitement, and to injuries arising during sexual con- 
gress and the important function of parturition ; and hence it is 
very satisfactorily shown that matrons are more disposed to or- 
ganic disease by a very large majority. Thus " of 98 affected 
with polypus, carcinoma, fungoid disease, and hard tumours, 89 
were married and six single." P. 5. 

The third question considered by the author (p. 5) is, " Whether 



ORGANIC DISEASES OF THE UTERUS. 37 

the diathesis accompanying organic disease impairs the faculty of 
conception?" The result of Dr Lever's experience tends to 
prove that such a disposition exerts very little influence in limit- 
ing the frequency of conception; and accordingly, of the 89 
women already referred to, 8 only were barren. This is quite 
in accordance with our own experience. We cannot remember 
a single instance of chronic organic disease of the uterus in a 
barren female ; while all the applications that have been made to 
us were by matrons, some of them indeed with rather a numerous 
progeny. And on considering that the ovaries, not the uterus, 
hold the first rank in the reproductive system of the female, we 
should not expect that the latter organ, except when the seat of 
extensive morbid lesion, would exert much influence in impairing 
the reproductive function. 

The fourth and last question considered by our author is, 
" Whether organic disease interferes with the vitality of the 
offspring?" Our own impression, derived from many years' 
experience, though not on so extensive a scale as that which Dr 
Lever has had the good fortune to enjoy, is, that the vitality of 
the foetus, except when there is severe constitutional disturbance, 
and not always even under these circumstances, is not compro- 
mised. We have been consulted in cases of enlargement and 
remarkable incrassation of the cervix uteri, and where, but a 
few weeks previously, such individuals had produced living chil- 
dren at maturity : we have known women with cauhflower ex- 
crescences of the OS uteri produce living children at maturity, 
though for many weeks previously they endured paroxysms of 
excessive pain, and copious hemorrhagic and leucorrhoeal effu- 
sions : and we have somewhat recently assisted at a labour which 
was protracted in consequence of the os and cervix being the seat 
of numerous cauliflower excrescences, and other fearful disorgani- 
zations; but a living, mature, and an apparently healthy off- 
spring was produced. Our author's experience on this head is 
very satisfactory. " 81 women conceived 553 times, 43 con- 
ceptions terminated in abortion, and 510 children were born at 
the full time ; and of these 510 children, only 12 were stillborn, 
owing in all probability, as it is inferred, to the non-dilatability 
of the parts, and consequent pressure on the foetus." P. 6. 

A considerable portion of the work is now taken up with some 
pertinent directions regarding the various modes of examination, 
the varieties of specula, and the manner of using these instru- 
ments. With these particulars we do not deem it necessary to 



38 ORGANIC DISEASES OF THE UTERUS. 

occupy the time of our readers, since the different methods of 
investigating uterine disease are familiar to every one, and since 
even the village apothecary must be intimate with the method 
of introducing the speculum, as it is now become so fashionable 
among the higher orders of the fair sex of this country, that were 
a practitioner not to employ it for the exploration of pelvic dis- 
ease, the patient would think herself quite neglected. We shall 
conclude our observations on this section of the work by a single 
remark on an expression used by our author (p. 8), viz. " dis- 
location of the uterus." To ourselves this phrase is new, and by 
no means so appropriate as the one we have been wont to em- 
ploy ; and were it not that the writer has shown so much good 
sense in the construction of his treatise, we should have been 
more than half inclined to think that either his tongue or his 
fancy had been dislocated when he used this expression. 

The next section of the work is devoted to the consideration 
of acute, sub-acute, and chronic inflammation of the uterus. Here 
we did not expect, nor do we 'indeed find, any thing new, except 
that we are informed (p. 39), " That not unfrequently women 
who have suffered from hysteritis do not again become pregnant, 
in most cases from closure of the Fallopian tubes;'' and that 
the use of ergot is followed by sub-acute inflammation (p. 43). On 
this last point the author will be permitted to speak for himself : — 

^ In some cases the inflamination is of a sub-acute kind from the firsts 
and especially in those where ergot has been given improperly. I had 
under my care five females attended by the same individual, to all of whom 
he had given the secale, and who were affected by the same symptoms." 

In regard to sterility being a sequence of hysteritis, Blatin and 
Nivet (p. 342) entertain the same opinion ; but so far as we are 
aware, they are the only modern writers, besides the author, who 
do so. Chambon, Boivin and Duges, and Duparcque, are silent 
on the subject ; and as to ourselves, although our experience in 
hysteritis, under the different forms particularized, has been 
pretty extensive, we have never had occasion to make any cor- 
responding observation. Were the Fallopian tubes at any time 
the seat of inflammation, or frequently subject to excitement, as 
they are liable to be in prostitutes, and their fimbriated extre- 
mities to cohere, in consequence, to some adjoining structure, 
barrenness would most probably be the result ; and, accordingly, 
cases are recorded where this has happened.* 



• Morgagni Epist xxvi. art. 14, xlviii. art. 32; Med. Chir. Trans. Lond.^ 
vol. viii. p. 603, vol xiii. p. 66. 



ORGANIC DISEASES OF THE UTERUS. 39 

The fact stated by Dr Lever respecting the secale is valuable 
in the extreme ; and we consider the profession under deep ob- 
ligation to him for his discernment. For ourselves, we can say 
little of this dangerous agent from personal observation ; but we 
venture to assert, from what little we have seen, and from con- 
versations with many of our brethren, that there is not a man of 
candour engaged in midwifery practice who could deny, if he 
were solemnly asked the question, that he had known the foetus 
destroyed where ergot had been exhibited. We regret much that 
Dr Lever has not stated what he means by its improper use, and 
under what regulations it had been exhibited in the cases to 
which he refers ; but we earnestly trust he will do so on an early 
occasion ; indeed he is bound to communicate his sentiments on 
this important subject. We can say that ergot has been followed 
by the most mischievous effects on the foetus, such as fractures 
of its cranial bones ; or when it escaped these injuries and was 
born alive, we have known meningitis supervene.* We have 
occasion to know, that as it was at one time with mercury in 
syphilis, so it is now with the secale — far too indiscriminately 
employed. Some of our brethren never think of going to a case 
of midwifery without being in possession of ergot ; but, however 
excusable it may be for gentlemen in the coimtry to go " armed 
at all points," in town, however, their doing so is most repre- 
hensible, since the agent in question might possibly be used to 
save time and trouble in a case in which, on mature reflection, it 
would never have been employed. 

In the treatment of chronic hysteritis, we find the following 
most judicious advice, and which we would strongly recommend 
to the attention of such of our brethren as are wont indiscrimi* 
nately to inundate the sexual canal with lunar caustic solutions, 
and other powerful astringents. 

"In the advanced stages, the decoct, papav. cum alumine, in the propor- 
tion of 3ij. of the latter to a pint of the former, is a very valuable remedy : 
but in employing vaginal injections, we must be especially careful to refrain 
from the use of astringents while there are symptoms of activity about the 
disease." P. 55. 

We coincide entirely with Dr Lever regarding the use of as^ 
tringents, which, when used at too early a stage, we have known to 
occasion distressing consequences by aggravating the disease, and 
rendering the case equally untractable with scirrhus itself. 

• For gome valuable observations on the injurious effects of ergot, and the regu- 
lations which should be observed in exhibiting it, see Campbells' Midwifery, 2d 
Edition, pp. 184 and 244. 



40 ORGANIC DISEASES OF THE UTERUS. 

We have next some very judicious directions for the treat- 
ment of the sequelae of chronic hysteritis. For hypertrophy of 
the uterus the author eulogizes very highly the use of leeches, 
mercury, and iodine. Of the former he directs six to be appUed 
to the uterus twice a-week ; he gives the preference to the hyd. 
c. creta given twice daily, until the system is gently affected ; 
and he employs the protoiodide of mercury with great advan- 
tage. 

We cannot do better than transcribe for the perusal of our 
readers one or two illustrations of the treatment pursued, from 
the work itself : — 

** E. P., set. 25, of fair complexion, and pale exsanguine countenance, 
married at 16, has given birth to five children, all of whom except the 
last were born alive. In her last labour the shoulder presented, the 
process continued 48 hours, and turning was practised. From the 
time of her delivery she has suffered from uneasiness, bearing down, 
constant weight, tenesmus, difficulty in micturition, and a copious leucor^ 
rhoeal discharge. The catamenia recur every fortnight, continue four or 
five days, and occasionally contain coagula. On examination per vaginam, 
the uterus was found to be increased in size and weight, and to press low 
in the pelvis ; a firm cicatrix was to be felt upon the middle of the pos- 
terior lip. When the hand was placed above the pubes, the enlarged 
organ could be readily detected. She was ordered hirud. xij, reg. pub. et 
inguin. bis hebdom. Fotus conii ter die injiciend. Pil. conii c. hyd. o. n. 
mist. mag. c. mag. sulph. ^ ter quotidie. This treatment was persevei*ed 
with for three weeks, when the medicine was changed for the following :^ 
Hyd. protoiodid. gr. ss. confect rosae canin. q. s. ft. pil. omni nocte 
sumend. hor& decubitus. R. pot. iodid. gr. iij. extr. sarsae. gr. x. ter die 
ex mist, camph. In this plan she persevered six weeks, and during that 
time she was twice leeched, as she suffered from severe pain. Tlie uterus 
became at first softer, then smaller, the intervals between the appearance 
of the catamenia more distant, while the secretion continued but three 
days, and was of a natural colour.'' P. 58. 

*^ M. T., St. 44, has borne nine children, and miscarried once. Menstru- 
ation commenced at 15, and during these periods she was frequently 
confined to bed from excessive pain. The secretion was skinny, and oc- 
casionally contained coagula. She had pains in the back, loins, and thighs, 
and the catamenia continued three weeks, with a white leucorrhoeal' dis- 
charge during the intervals betwixt the menses. In the last twelve 
months the catamenia have returned at intervals of from two to three 
weeks. On examining the uterus it was found enlarged, its vessels 
strongly throbbing, its weight much increased, aperture swollen, turgid, 
highly vascular, and of a livid colour, but free from abrasion. She was 
ordered 6 leeches to the vagina twice a- week, a mild astringent injection, 
the dec. tormentills c. alumine, and the following medicines: R. pil. 
hyd. gr. ij. ext. conii gr. iij. m. ft. pil. omni nocte sumend. R. mag. 
sulph. 3 as. tine, cinchon. c. 3j. syrup aurantii 3ss. infiis. gent. c. 3x. 
ft. haust. ter quotidie sumend. After continuing this treatment tc»n 
days her gums became rather tender, but the uterus smaller, less swollen 



ORGANIC DISEASES OF THE UTERUS. 41 

and taigid. She perseyered in this plan of treatment six weeks, and was 
then perfectly convalescent." P. 61. 

We come now to consider very briefly induration of the 
uterus as a sequela of chronic inflammation. Our author says that, 

^ Before resolving upon the treatment, we should first satisfy oniselves 
that the indnration is the result of chronic inflammation, and not the com- 
mencement of malignant disease. Induration, the result of chronic inflam- 
mation, may be known by its regular feel and by the history of the case. 
In most instances there has been the creamy discharge. Induration, the 
commencement of malignant disease, is in nodules, the malignant depo- 
sitions being generally secreted in central points." P. 64. 

We must beg leave to tell Dr Lever that he has treated this 
important point with far too much brevity, and we think not 
with strict correctness. If the diagnosis were as simple as the 
foregoing passage would lead us to believe, our duty in this respect 
would be easy indeed; but it is far otherwise, and two fre- 
quently the diagnosis cannot be established with any degree of 
confidence even by veteran practitioners ; and we are therefore 
a good deal surprised that the author has not enlarged on this 
subject. For ourselves, we have long been of opinion, not only 
that it is extremely difficult, if not impossible, in many in- 
stances to draw a line of demarcation between induration the 
result of chronic inflammation, and induration as the incipient 
stage of cancer, but that indeed the former degenerates into the 
latter ; and in these opinions we are satisfactorily supported by 
Boivin and Duges (vol. ii. p. 277), and Duparcque (vol. i. p. 
242), who are the most recent and among the best authorities 
on uterine diseases. To the writings of Sir C. M. Clarke we 
shall not refer, because though valuable at the time they were 
published, the pathology of organic diseases of the uterus was 
then, comparatively speaking, in its infsuicy. For indurations 
iodine and mercury are highly eulogized, with the local abstrac- 
tion of blood by scarifying the os uteri, and the use of aromatic 
tonics, as columba and cascarilla. In the early stages of this 
variety of degeneration we are quite aware that much may 
be done to benefit the condition of the patient ; but while we 
would encourage perseverance in the use of the means parti- 
cularized, we consider it but just to caution our younger brethren 
agaunst being too sanguine of success ; for those cases, as every 
candid and experienced practitioner must avow, too frequently 
baffle the best-directed efforts. 

The fourth sequela of chronic hysteritis noticed by our 
author (p. 68) is simple rdcerationy which he informs us, and 



42 ORGANIC DISEASES OF THE UTERUS. 

very properly, can only be elicited by ocular inspection aided 
by the speculum, for the ulcer sometimes does not exceed a pin- 
head in size. " In many cases the ulcer resembles a cut 
surface ; in some it is thin, shallow, and deeper than the mucous 
membrane, while not unfrequently it bleeds upon the slightest 
touch." These cases are preceded by symptoms of inflammation, 
as rigors, reaction, fever, obtuse pain, a sense of dragging in 
the loins, weight in the anus, increased uneasiness during 
menstruation, pruritus of the vulva, and leucorrhoea varying in 
colour and consistence, usually streaked with blood. The 
posterior lip of the os uteri is thought to be more frequently 
the seat of ulceration than the anterior, but either may be 
affected. Among other causes, the author particularizes the 
use of irritating astringent injections, a practice the most re- 
prehensible where there are such symptoms as indicate irrita- 
tion of any pelvic viscus, and against which we cannot too 
often reiterate our disapprobation. 

We give the following passage as the author's sentiments 
regarding the diagnosis betwixt simple, syphiUtic, and corroding 
ulcers, without at all assenting to the opinion that these different 
lesions are to be distinguished from each other so easily as the 
brevity of Dr Lever's remarks, and the air ofc confidence with 
which they are written, might lead a reader unacquainted with 
these subjects to infer. We need only remind practitioners of 
the difficulty of deciding in cases of syphilis, even, though so fre- 
quently accustomed to examine them, whether the sore be of 
this nature or not, unless from the moral character of the patient 
there be strong presumptive evidence. 

Diagnosis, — " They may be distinguished from syphilitic ulcerations by 
the regular hard edges of the latter, by the yellow sanious discharge ; and 
in some cases assistance is gained from the moral character of the female. 
Its limited extent and superficiality, its slighter constitutional effects, the 
absence of large bleedings, and the discharge, distinguish it from corroding 
ulcer ; while from the malignant cancerous ulceration it may be recognised 
by the want of hardness from morbid deposit, by the nature of the pain, 
and the character of the discharge." P. 69. 

Dr Lever's treatment of these cases is very judicious, and 
were it not for our circumscribed Umits, we should feel justified 
in quoting the whole of it, but we trust to the professional com- 
munity consulting it for themselves, as it will amply repay them. 
In the acute stage the local abstraction of blood is inculcated, 
with other agents calculated to allay irritation ; and in chronic 
cases the direct application of lunar caustic and the improvement 



ORGANIC DISEASES OF THE UTERUS. 43 

of the general health are recommended, and we entirely concur 
in the recommendation. 

The next section is devoted to the consideration of ulcers on 
different parts of the uterus in cases of procidentia, which re- 
quire nearly the same remedial means as similar lesions affecting 
the organ while in situ. To the foregoing succeeds a succinct 
notice of enlargement of the glands of the os and cervix tUeri 
as a sequela of hysteritis, which is characterized by pruritus 
amounting in some instances to nymphomania, slight leucorrhceal 
discharge, and occasionally redness of the vagina, which may be 
the result of frictions by the patient herself. By the aid of the 
speculum — ^and no other mode of exploration should be confided 
in — small granules, not unlike millet-seeds, white, soft, seemingly 
vesicular, and numerous, are observed. For these cases, cupping 
or leeching, according to the amount of irritation, or in the 
absence of tenderness^ solutions sulph. ferri or nitrat. argenti 
are recommended. All these sequelae of hysteritis are illustrated 
by cases which greatly enhance the value of the work. 

Part IL of this publication (p. 79) embraces what the author 
denominates Specific Diseases^ viz,, first. Tumours of the Uterus, 
which are allowed by all writers not to possess any malignity, 
as polypus; and, secondly. Fibrous Tumours. Though un- 
questionably a most valuable section of the treatise, we are never- 
theless obliged to pass it without comment, and with the exception 
of a solitary case, without quotation, since the subjects embraced 
have recently received great attention, and must be familiar to 
all our bretlu'en who feel an interest in the diseases of females ; 
but Dr Lever must not on this account suppose that we consider 
his second in importance to the additions which have of late been 
made to our knowledge in this department of practice. From 
this portion of the work we quote the following instance of a very 
rare disease, viz. Strumous Tubercles of the Uterus. We shall be 
excused for this lengthened quotation when we state that Louis 
met with only one instance in 358 cases which he had examined. 

Case XXX. — "I was requested to visit a lady of 26, who had been 
married only ten days, and had previously enjoyed good health. After 
her marriage she went on a long journey, and while some distance from 
home, in descending the stairs of an hotel, she felt a pain at the lower part 
of the abdomen. The uneasiness did not subside, and was accompanied by 
sickness, impaired appetite, &c. The bowels were regular, but the pulse 
was excited. She missed her next monthly period, and the sickness, if any 
thing, increased ; as also the uneasiness in the abdomen, and her countenance 
hecame anxious. In about three weeks there was a decided fulness in the 



44 ORGANIC DISEASES OF THE UTERUS. 

lower part of the stomach, and upon carefdl examination a tnmonr could - 
be felt. The pain over the swelling was greatly increased by presBure ; 
the sickness augmented ; the emaciation increased ; her appetite became 
less ; and notwithstanding tonics, iodine, &c., were prescribed, this young 
lady became decidedly worse. I consulted with two eminent physicians, 
and they concurred with me in opinion that this young lady was not 
pregnant, that the disease under which she was labouring was tubercular 
peritonitis, and that the tumour in the region of the uterus was probably a 
large tubercle, or a cluster of tubercles. Vaginal examination detected the 
uterus to be completely fixed in the pelvis. Within five months from the 
date of marriage, this lady (without the menses having made their appear- 
ance) became greatly emaciated. The immediate cause of her death was the 
giving way of the diseased intestines, and consequent escape of their con- 
tents into the abdomen, causing peritonitis. Upon examination the whole 
of the peritoneum was found to be studded with tubercles ; attached to 
the uterus there was one of very laige size ; while, in addition, the whole 
of ' the structure of this viscus was completely infiltrated ; in fact, the 
tubercular deposit appeared to be universal throughout the body. This 
case was. remarkable from the patient being very robust and stout., with 
rosy cheeks, &c., before marriage ; and from her being seized, ten days after 
marriage, with acute pains which continued until her decease." P. 132. 

Part Third of the work, extending to about ninety pages, 
embraces what are styled malignant diseases of the uterus ; such 
as cauliflower excrescence, corroding ulcer, melanosis, and cancer. 
As it would be pure waste of time to enter into any elaborate 
comment on these subjects, since, generally speaking, they baffle 
our ingenuity and judgment, and that scarcely any thing can be 
said regarding them beyond what is already well known, our 
readers will excuse us if we merely take a rapid glance at each 
of them in succession. Our author gives a very good description 
of cauliflower excrescence, which he says 

" Consists in the growth of a highly vascular tumour, of a bright flesh- 
colour, with a granulated surface, generally growing from a part or the 
whole of the os uteri, and sometimes also from the uterme cavity. This, in 
comparison with the other organic diseases of the uterus, is rare, our author 
having met with it only G^ree times in a list of more than 350 cases of 
cancer of the womb. The structure of this excrescence is pretty firm ; but 
still, if pressed strongly by the finger, it bleeds. It has a very fine mem- 
brane spread over it, which secretes a copious watery fluid. After death 
the tumour disappears, nothing being left but a mass of flocculi, apparently 
empty vessels : the same effect takes place when the excrescence is noosed. 
If a ligature be applied, and the tumour removed beneath it, it will 
rapidly grow again. It has been met with in females of all ages, tempera- 
ments, and habits, and in the single as well as the married ; injuries during 
labour have been supposed to occasion it, but this would not account 
for it in females who never had a family ; by others syphilis and excessive 
coition have been thought to lay a foundation for it, but prostitutes do 
not seem to be more subject to it than virtuous and prudent females. It 
commences with a moisture in the external parts, amounting very soon to 



ORGANIC DISEASES OF THE UTERUS. 45 

a oopions wa^ry dischaiige from the Tagin% in quantities geneiall j so 
profuse that several napkms are moistened daily. The countenance be- 
comes blanched and sallow, eyes sunk, vision impaired, pupils enhu^^, 
respiration hurried during exertion ; there is palpitation, pain in the left 
side, despondency, dyspepsia, thirst, emaciation, tympanitis, and oedema of 
the pelvic limbs. At first the discharge per vaginam is merely streaked with 
blood, but it soon becomes quite hemorrhagic. The ordinary examination 
merely will excite bleeding." P. 138. 

The foregoing corresponds very nearly with our own expe- 
rience in four cases which came under our observation : in the 
firsts the patient was seven months pregnant, and there were 
three tumours, each the size of a child*s clenched hand, attached 
to the OS uteri ; the second was a lady about 55 years of age, 
with only one excrescence of this character, like a cWld's flattened 
hand, growing from the posterior lip of the uterus ; the third 
was a lady of 52, with a tumour of this nature the size of a small 
pear, growing from the interior of the uterus, but unlike all the 
other cases we met with, it was so soft that the least interference 
broke off portions of it ; and the fourth case we met with recently 
in a woman in labour, attached to whose os uteri there were five 
or six of these tumours, from the size of a filbert to that of a 
wabut. As no other than the most unfavourable prognosis can 
be offered in the foregoing cases, we shall merely make a bare 
enumeration of the means which have been used for relief, and 
which can only be considered as palliatives : these are, excision, 
caustic, with the more powerful vegetable and metallic astringents, 
tonics, a bland nutritive diet, and abstinence from stimuli and sex- 
ual congress. 

We are next (p. 145) furnished with a description of corroding 
ulcer, of which, as it resembles cancer in many particulars, and 
is equally intractable, we shall merely state its principal features. 
This term was first used by Dr John Clarke, to a disease which 
consists in a malignant ulceration of the os and cervix uteri, the 
remainder of the organ being scarcely even enlarged. One sin- 
gular feature of the disease is, that there is no deposition of new 
morbid matter in any part which it affects. It may extend to 
the bladder, rectum, or to the upper regions of the uterus. The 
glands about the cervix are the structures first affected, and most 
frequently in females verging towards forty, or the period when 
the catamenia take their final leave. When the parts are ex- 
amined after death, sufficient evidence is displayed of serious de- 
vastation of structure, but without induration, hypertrophy, or 
new deposit. 



46 ORGANIC DISEASES OF THE UTERUS. 

^ Females of a lymphatic temperament are said to be more liable to the 
disease than other subjects. It is preceded by an occasional sense of un- 
easiness in the pelvis, heat, and leucorrhoea, all of which are unfortunately 
too often disregarded until hemorrhage appears. As the malady advances 
there is emaciation, dyspepsia, gastric irritation, sallow countenance, excited 
pulse, a sense of general weakness, of weight and pain in the back, extending 
to the loins and around the lower part of the abdomen. The pain varies, 
producing an obtuse, lancinating, or burning sensation. The hemorrhage 
jrecurs, sometimes with an alleviation of the uneasy feelings ; and during the 
intervals there is an ichorous discharge from the vagina, so acrid as to exco- 
riate the external parts. For some time at first the patient's complaints 
are considered hysterical, and her ailments receive no attention until 
hemorrhage appears, when an examination per vaginam is granted, which 
discovers an amount of mischief previously unsuspected. If we trust 
to the ordinary examination, the ulcer, unless large, may not be discovered, 
for the patient scarcely complains of pain when the finger is brought into 
contact with it." P. 146. 

Some years ago we had occasion to be consulted in a case of 
this nature, which two other physicians — one of them most ex- 
perienced — ^hadsome time previously seen ; but the patient being 
considered by them to be merely hysterical, and her friends 
advised not to encourage her whims, no local treatment was 
adopted. The day after visiting this individual, the speculum 
was used for the first time, and a large ulcer discovered in the 
posterior Up of the os uteri. She ascribed her complaints to ill 
usage from her husband, and died three months after we had been 
called. In every suspicious case, as exploration by the fingers 
is insufficient, the speculum must be employed ; and by it we 
shall probably eUcit — ^not a deep ulcer — ^but one much extended, 
with a rough granulated surface. A marked feature of this com- 
plaint, and which distinguishes it from carcinoma, is, that the 
uterus possesses fully as much mobility as in a state of health, and 
that it is not enlarged. Ulceration advances until a breach is 
formed in the bladder, or in the rectum, or in both, which reduces 
the patient to a loathsome condition, and soon terminates her 
sufferings. 

Dr Lever tells us that these are hopeless cases, and for an 
obvious reason ; because, from the natural deUcacy of the sex, an 
examination is too frequently resisted until the disease has made 
such progress that neither excision nor any other remedy can 
avail. Were an opportunity afforded of making an efficient in- 
spection of the uterus when its os or cervix is merely in a high 
state of irritation, or even ulcerated in a trivial degree, the prac- 
titioner should not despair of procuring permanent relief by 
cupping on the sacrum, and the local application of leeches ; 



ORGANIC DISEASES OF THE UTERUS. 47 

caustic after excitement has been subdued, and other appropriate 
measures. Dr Lever says (p. 151), that " if, when first con- 
sulted, we are certain of the nature of the ulceration, and if there 
be a septum of healthy tissue between the disease and body of 
the uterus, in my opinion we should act wisely by excising the 
OS uteri." We are happy to state that there is (p. 209) but one 
other siich absurd passage in the volume before us ; if there had 
been many, we certainly should not have devoted so much time 
to its analysis. The commencement of the disease is the only 
time for even contemplating excision ; and we defy the most ex- 
perienced to decide what is the nature of the complaint at that 
stage ; and, secondly, we deny that the os and cervix, while the 
uterus is in situ, can ever be examined with such precision, how- 
ever practised and acute the eye may be, as to determine if there 
be a septum of healthy stcucture between the diseased point and 
the body of the womb. We hope, therefore, that no one will 
act on the dictum of Dr Lever by practising excision, but, on 
the contrary, trust, in the incipient stage, to local bleedings — 
an antiphlogistic regimen — ^hip warm bath, with strict tranquillity 
of mind and body, which we are confident will be found far safer 
and more certain than the knife, the utility of which must at 
best be problematical, and may only accelerate the fatal cata- 
strophe. 

We have next (p. 151) a case of very rare disease, viz. 
Melanosis of the uterus, in a woman of 45, who was at 
first supposed to be the subject of hard fibrous tumour. She 
had been more than twelve months complaining when she 
applied to the author. Four months from the date of her appU- 
cation, a profuse flow of blood escaped per vaginam, and con- 
tinued for a long time, followed in the course of a few days by a 
dark, brownish black discharge, having a peculiar odour. In 
six weeks from the commencement of the hemorrhage, she was 
carried off by a diarrhoea. On dissection, the uterus was found 
enlarged, and a tumour at the right and anterior part of it, the 
size of a fist, developed in the proper structure of the organ. 
This adventitious formation varied in consistence, being firm 
externally, and much softer towards the uterine cavity; the 
mucous membrane covering it was destroyed, and the tumour 
itself converted into a melanotic mass. 

Cancer uteri is divided by our author into three stages, the 
premonitory symptoms constituting the first. This division we 
consider a useless refinement, and partaking somewhat of that 



48 ORGANIC DISEASES OF THE UTERUS. 

disposition for generalizing so characteristic of our Gallic neigh- 
bours ; but to gratify the writer, we shall follow him very briefly 
in what he considers the first stage. 

'^An examination per vaginam discovers the edge of the os uteri in- 
durated, sometimes fissured, irregular in form, projecting unusually into 
the vagina, studded, in the situation of the muciparous glands, with projec- 
tions which feel like gravel or grains of shot, that become paiuful on 
pressure, which also occasions sickness. The use of the speculum displays 
turgidity of the os uteri, which will be seen of a deep crimson colour, while 
the projecting shot-like points present a bluish hue. As yet the disease is 
confined to the os and lower part of the cervix, and the uterus is generally 
moveable. This state is very tardy in its progress, for we have knoMm it 
continue with little alteration for years. 

*' In the second stage the uterus subsides considerably in the pelvis, by 
its weight and change of position interrupts the functions of defecation 
and micturition, and occasions uneasiness while the patient is either in the 
erect position or walking. The lancinating pains, which were at first but 
trivial and rare, are now frequent and severe, and the discharge from the 
mucous lining is increased, occasionally stredsied with blood ; but as yet 
it is destitute of foetor and acridity* The uterus is now tumefied and 
indurated, its aperture notched and dilated, and the organ is less moveable 
than in the first stage. Previous to ulceration taking place, we may by 
ocular inspection be able to discover some one point of Uie indurated part 
softer than the rest ; and in this spot, which feels very painful, idceration 
will commence. During this inspection also, the cervix presents a swolleui 
tense, and shining appearance, a spongy feel, and a deep brown colour. 

^ In the third stage the pains are much aggravated, described as lancinat- 
ing, burning, or gnawing, recur in paroxysms, more severe at night than 
during the day-time, occasionally accompanied by sanguineous dischai^es, 
which are the first indications of a breach of continuity, and in their 
absence leucorrhcea of the most offensive odour. This latter discharge 
changes in colour from brown to dirty white, green, or black, slightly 
effervesces with sulphuric acid, and turns syrup of violets to green. As 
the disease progresses, the bladder and rectum are perforated, the latter 
more frequently than the former. An examination of the interior of the 
pelvis detects a hard, irregular, immovable mass, filling its cavity, the os 
uteri considerably more dilated than usual, indurated, painful to the touch, 
and bleeding on the slightest interference." 

Dr Lever does not believe that the disease can be transferred 
from one subject to another, neither do we. He says, 

*' I have for some years paid particular attention to this question, in 
order to ascertain whether the husbands of women affected with ulcerated 
carcinoma have contracted the disease^ and in no instance have I l>een able to 
detect the supervention of cancer in the male,** 

But although the complaint cannot be. transmitted, we quite 
concur with our author in thinking it hereditary. He says, 

**Ihave seen several instances of mothers and daughters dying from this 
malady; and in one instance, I traced the disease through three generations, 
the grandmother, mother, and daughter, all falling victims to it. The regi»- 



ORGANIC DISEASES OF THE UTERUS. 49 

ters of the obstetric out-patients of Guy's Hospital show that the propor- 
tion of cases of carcinoma uteri to other cases of uterine disease is nearly 
as 1 in 7." 

Females of a lymphatic temperament are thought to be most 
disposed to it ; and from what was stated in the commencement 
of this analysis,' those who hare been martyrs to dysmenorrhcea 
must certainly be included in the Hst. We consider mental 
anxiety, the depressing passions, repeated abortions, and a la« 
borious occupation, fertile exciting causes ; and though denied by 
our author, we have had many painful proofs that gonorrhcea 
may be viewed in the same light. Dr Lever satisfactorily 
repudiates the opinion that virgins are more subject to the dis- 
ease than married women ; from his observations {Med. Chir. 
Trans. Land., vol. xxii. p. 269) it would appear that from the 
" 40th to the 60th year is the most frequent period of attack. 
Of those afiFected, single women bear a proportion of 5.83 per 
cent., married women, 86.6, and widows, 7.5." We also extract 
the following interesting statements: " The number of women 
with fair complexion affected with cancer uteri amounted to 20.8 
per cent., of those with dark complexion, 79.16 per cent. ; 25 or 
20.8 per cent, enjoyed good uterine health in early life, while 
95 or 79.16 per cent, had suffered from functional disease or 
syphilis ; death occurred in 107 cases, the average duration of 
the cases being 20^ months ; the shortest duration of the disease 
was 3 months, and the longest 66 months." 

In remarking on the Prognosis, our author believes, and we 
unhesitatingly agree with him, that after the disease has passed 
mto the stage of scirrhus, it is quite hopeless. 

On the subject of Diagnosis, we are told to rely on the shot- 
like bodies deposited in the seat of the ova tiabothi, the presence 
of induration, and the less sensitive condition of the diseased 
structures in carcinoma uteri, to enable us to distinguish this 
from irritable uterus. From simple induration, scirrhus is known 
by the greater hardness of the part affected, its being more 
lobulated, by the increased deposition into the surrounding struc- 
tures, and the uterus being less moveable. 

In the treatment, the author places great reliance, during the 
first stage, on cupping upon the sacrum, the direct application of 
leeches to the uterus, anodyne injections, mercury to produce a 
gentle effect, in combination with opium, hyoscyamus, conium, 
or camphor ; while the liq. potass, arsenit. is highly eulogized 
for subduing uterine uneasiness. Counter-irritants are also 

G 



60 THE PHYSIOLOGY OF INFLAMMATION. 

recommended, as a succession of blisters, or an issae oyer the 
sacrum, or either sacro-iliac symphysis. All stimuli — ^regiminal, 
mental, and sexual, should be strictly avoided ; while tranquiUity 
and ease are to be sedulously obseryed. Our author does not 
seem favourable to the excision of the os uteri, neither does any 
practitioner of this country, except such as are guiltless of com- 
mon sense. We are saved the trouble of considering the merits 
of the merciless and sanguinary operation of removing the uterus 
while in situ, or emboweling a woman alive, since in this coun- 
try, and on the Continent, indeed, that expedient is disapproved 
of in the most emphatic language, by those even who performed 
it successfully. 

We now take leave of Dr Lever by wishing him every suc- 
cess in his endeavours to enlighten the profession; and by 
strongly recommending our brethren to possess his work, as one 
from which the veteran as well as the tyro will derive much 
valuable information. 



The Physiology of Inflammation and the Healing Process. By 
Benjamin Travjbrs, F.R.S., Surgeon Extraordinary to the 
Queen, &c. &c. 12mo. Pp. 226. 

It is not wonderful that inflammation should occupy so much of 
the thoughts of the medical profession. It is the field in which 
medicine achieves its most signal triumphs. And should an 
occasional doubt arise in the mind as to the reality of the empire 
of medicine over diseases, with ordinary discernment, it is most 
easily silenced by reflecting on the ravages of acute inflamma- 
tion in some seasons, and on the power of the lancet to check its 
destructive progress. 

No doubt, there are periods, the medical constitution of which 
(so to speak) is but faintly distinguished by a tendency to that 
highly acute inflammation of vital parts which the lancet so 
effectually combats ; and there are times when the pathology of 
the day is apt to take one-sided views, and to draw its colour 
too exclusively from a few sources, without surveying the whole 
of the wide range which diseases occupy. 

Even our own time, marked as it is by the extensive diffusion 
of medical knowledge, is not exempt from the suspicion of being 
subject to some undue influence of this kind. And what with a 



THB PHYSIOLOGY OF INFLAMMATION. 51 

too exclusive attention to the course of inflammation in hospital 
practice,* among patients debilitated by previous diseases and by 
the poverty and vices of large towns, what with an unequivocal 
defect of the strong disposition to high inflammation in tiie me- 
dical constitution of the seasons, for some time past, we are now 
and then threatened with the rise of a scepticism as to the in- 
herent fatality of acute inflammation when left to run its course. 

We cannot give to this temper of mind the praise of rational 
doubt. We regard faith in the power of the lancet over the 
early stage of acute, unembarrassed inflammation, as the test of 
a medical man's soundness of judgment and fitness for the dis- 
charge of the trust reposed in him by his patients. And judging 
of the future from the past, we feel assured that times will come 
round, and that often, when a perseverance in such doubts will 
prove the source of bitter repentance to those who foster them. 

Next to experience, in a proper sphere, of the effects of vene- 
section over inflammation, ranks a careful study of the facts and 
events of this morbid action, to preserve a right frame of opinion 
over so important a subject. And we augur well" against the 
spread of the scepticism referred to, from the extended attention 
given at present to the phenomena and pathology of inflammatory 
action. 

The theory of inflammation has always been an attractive sub- 
ject among medical writers. The theory, however, is less im- 
portant at present, and less within our reach than the facts. The 
work of Mr Travers, which we have placed at the head of this 
article, turns less upon the theory than upon the facts and events 
of the whole disease. The fault of all our past theories of this 
disease has been the too sparing amount of facts founded on. 
And numerous as have been the additions made of late years to 
our knowledge of such facts, we shall discover, on a very tran- 
sient inspection, that it is the want of a few additional facts that 
renders it impossible to bring out a satisfactory theory of inflam- 
mation. The facts of a disease are not distinct from the theory, 
the theory being the facts generalized ; and while a perfect theory 
is unattainable, the facts, when they are numerous, as those 
ascertained respecting inflammation are, serve nearly the same 
uses as a sound theory. And, iu particular, the knowledge of 
the facts of inflammation, and that of its theory, have each the 

* See Alison in Library of Medicine, yoL i. p. 100. 



62 THE PHYSIOLOGY OF INFLAMMATION. 

same paramount object in medicine, namely, to fix and extend 
the great precepts of treatment, which experience at first sug- 
gested. 

The theory of inflammation, defective as it may still seem on 
a superficial view, is already more complete than that of any 
other extensive kind of morbid action. It is already quite abreast 
of the physiology of the functions involved in the disease, and 
beyond that it plainly cannot pass. Physiologists have not yet 
settled the relative shares taken by the heart, the arterial trunks, 
and the capillaries, nor the ordinary influences operating on these 
last vessels, in the transmission of the blood during health ; or 
the facts, in so far as inflammation itself is in question, are nearly 
all already ascertained, and prepared to be incorporated with 
whatever principle physiology shall point out as apportioning the 
moving forces of the blood among the agents concerned. 

The discussion so long agitated, whether the vessels of the 
inflamed part be in a state of augmented or enfeebled action, may 
now be discarded as having served its turn. The terms of this 
question are* not precise enough — ^not sufliciently square with 
the facts known respecting the state of the capillaries of an in- 
flamed part, to admit of an answer in the negative or affiimative, 
as regards increased or weakened action. 
. As the work which has suggested these reflections has for its 
chief object the exposition of the facts of inflammation, we pro- 
pose, before going farther into the subject, to endeavour to ex- 
hibit, in the form of distinct propositions, a connected view of 
what appear to us the most important facts which have been 
authenticated in the pathology of inflammation. 

1. That there is no increase in the rapidity of the blood's 
motion through the capillaries adjacent to the axis of an inflamed 
part, except for a short period at the very commencement of the 
disease. 

2. That the diameter of the same capillaries is diminished 
during the time that the more rapid motion continues. 

3. That in those capillaries adjacent to the axis of the affected 
part, as soon as the inflammatory action is estabUshed, there is 
either a very slow motion or a total stagnation of the blood. 

4. That the slow motion or stagnation in the capillaries near 
the axis is attended with a considerable dilatation, or increase in 
their diameter. 

5. That ia the capillaries at the periphery of the inflamed 



THE PHYSIOLOGY OF INFLAMMATION. 53 

part, the blood flows, during the continuance of the disease, with 
unusual rapidity, and that in the mean time the diameter of 
these capillaries is diminished. 

6. That the period which elapses between the commencement 
of the temporary acceleration of the blood in the capillaries ad- 
jacent to the axis of inflammation, and its retardation or stagna* 
tion in the same, varies from a few minutes to several hours. 

7. That in the rise of the inflammation, the blood in the cen- 
tral capillaries oscillates, or to some extent flows backwards and 
forwards, before it finally stops. 

8. That this oscillation of the blood, or its forward and back- 
ward motion in the central capillaries, soon after the first com- 
mencement pf inflammation, is synchronous with the action of 
the heart. 

9. That no entire blood or blood-corpuscles escape, unless a 
breach of continuity in the enlarged capillaries somewhere occur ; 
that even the minutest extremities of the capillary vessels are 
closed, and effuse their contents through their walls, by which the 
entire blood-corpuscles cannot pass, but only the serum, lymph, 
or Uquor sanguinis. 

10. That the several conditions of absolute stagnation, slow 
motion, oscillation, and rapid motion of the blood, are seen at the 
same time, on examining the inflamed area from its central axis 
to its peripheral boundary. 

11. That coincidently with the slow motion or stagnation of 
the blood in the central capillaries, its vesicular part or eorpuscles, 
which in health move in the axis of the vessels without touching 
their sides, separate from the liquor sanguinis, concrete into 
masses, and adhere to the inner surface of the walls, so as to 
impede all motion. 

12. That even after inflammation has advanced thus far — 
that is, to the enlargement of the capillaries — ^the stagnation, 
slow motion, oscillation, and rapid motion in the capillaries, ex- 
tending from the axis outwards, and the separation of the blood- 
corpuscles from the liquor sanguinis, their concretion into masses, 
and adhesion to the walls of the containing vessels, the motion 
of the blood may slowly return to its healthy state, without any 

.exudation of liquor sanguinis, hemorrhage, or even effusion of 
serum. 

13. But when things have come into the state referred to, 
that liquor sanguinis, that is, blood freed from the corpuscles 
only, most commonly eiAides. 



54 THE PHYSIOLOGY OF INFLAMMATIOK. 

14. And that this Hquor sanguinis, separating after exudation 
into serum and coagulable Ijmph, affords these well-known most 
usual products of inflammation. 

15. Further, when the stagnation is considerable, that the 
fibrine of the hquor sanguinis concretes on the inner walls of the 
capillaries, small arteries, and venous radicles, as well as on the 
adjacent free surfaces, or in the interstices of the affected paren- 
chyma. 

16. That by this concretion of fibrine within the vessels, the 
stagnation is rendered more complete, extensive, and permanent ; 
and hence that total failure of nutrition in the part or gangrene 
is threatened. 

17. That the repulsion between the red corpuscles and the 
liquor sanguinis during inflammation is apparent even in the 
blood taken from a vein, giving rise to the buffy coat, to which 
there is a stronger tendency, after an inflammation has continued 
some time, than at its commencement. 

18. That when the effused coagulable lymph, that is, the 
fibrine of the hquor sanguinis, becomes organized, as in the case 
of adhesion between two free surfaces, or of the thickening 
of a membrane, it is by the agency of the red corpuscles that 
new vessels are formed. 

19. That as stagnation begins to cease in the dilated capilla- 
ries, and motion comes to be recovered, separation of the con- 
creted red corpuscles takes place, and oscillations or shght move- 
ments backward and forward arise, by which single blood-cor- 
puscles are projected through the ruptured walls of the capilla- 
ries into the adjacent concreted lymph; that the tracks thus 
formed gradually pass into loops and arches by the concurrence 
of corpuscles projected from different points, which become ves- 
sels, and quickly receive files of blood-corpuscles from the adja- 
cent old capillaries, in which the blood is recovering its motion. 

20. That the granulations in wounds and the pyogenic mem- 
brane in abscesses are organized in concrete coagulable lymph on 
the same general plan ; while the part so organized exudes or 
secretes pus, or if not pus, the fluid material out of which pus forms ; 
and it may be that in other instances of suppuration, organized 
coagulable lymph performs a similar office. 

21. That ulceration is the result of decomposition or absorp- 
tion, when that is riot balanced by the activity of nutrition in the 
new texture. 

22. That the artery feeding an inflamed part and the parts 



THE PHYSIOLOGY OF INFLAMMATION. 55 

immediately adjacent, beats., more strongly than in health, while 
in a giyen time a greater quantity of blood, even by three or 
four times, is transmitted through it, as well as by its corres- 
ponding vein. 

23. That this artery and this vein may generally be dis- 
covered by the touch to be more distended with blood than 



24. That though an increase in the force and frequency of the 
heart's action be not absolutely essential to inflammation, yet 
that it is evidently a part of its phenomena in every case in 
which the disease is rapid in its progress or extensive in its seat. 

25. And that the stroke of the pulse in the radial artery, most 
characteristic of the presence of unembarrassed inflammation, 
" seems as if it were produced by a number of detached globules 
passing in succession through the artery."* 

26. That the severity of the symptoms in some external inflam- 
mations, as gout, whitloe, and the like, may be relieved, and the 
attack even cured, by compression of the artery supplying the 
part.f 

27. That whatever tends in the early stage to diminish the 
fulness of the vessels in the region of the inflamed part, and the 
general momentum of the mass of the blood, and when the case 
is severe, free venesection in particular, has manifestly a great 
power to prevent the effusion of the liquor sanguinis and the 
other events of inflammation, by assisting to restore the circular 
iion of the part to its natural state. 

28. That nothing so clearly shows this as the well-known 
effect of excessive venesection to interrupt the progress of the 
healing process in the case of wounds and other injuries. 

Such, then, are some of the facts, the generalization of which 
should constitute a theory of inflammation. . A perfect theory 
should in the first place connect the causes of inflammation with 
the acts which represent the first stage, and then the first stage 
with the subsequent progress of the disease. 

The kind of explanation which past experience in the science 
of life entitles us to expect, by the cultivation of this subject, is 
not a reference of the secret workings of the stream of life, in 
its capillary channels, when inflammation has sprung up, to the 
same head exclusively with any modes of action known among 

* See Parry, Elements of Pathology and Therapeutics, p. 56. 
t Parry, Memoirs of the Medical Society of London, voL iii. p. 77 ; i^w Kcllie, 
Medical Effects of Compiession by the Toumiquet. 



56 THE PHYSIOLOGY OF INFLAMMATION. 

mechanical or chemical phenomena, or in any part of pm*ely physi- 
cal natm'e. The gromid on which the explanation sought must 
rest cannot be any thing else but principles discovered in the 
living body itself. Or we obtain an explanation of a particular 
act of the living body, whether healthy or morbid, when that act 
is shown to be a special instance of the operation of laws before 
established by the generalization of facts observed in the animal 
economy in health or disease. 

While, however, the expectation of reducing the phenomena 
of inflammation to any purely physical laws, is plainly chimerical ; 
stiU it is not to be forgotten that mechanical principles must 
operate in a disease, the very essence of which is an extensive 
disturbance of the circulation of the blood. In the circulation 
the greatest share of the powers concerned is purely mechanical. 
And therefore no theory can be satisfactory, which does not show 
how much of the process can be ascribed to mechanical causes, 
at the same time that the claims of the purely vital forces are 
rightly vindicated. On this point we quote the following pass- 
age from the first chapter of the work before us, which Mr 
Travers entitles Preliminaries : — 

^^ Most of the theories of inflammation are based upon the fact of an obstruc- 
tion to the passage of the blood, whatever be the cause, real or supposed, of 
such obstruction. Some have represented this remora as mechanic^, others 
as chemical, others again as a nervous phenomenon. To constitute inflam- 
mation it must be all or neither ; for the mechanical, chemical, and vital 
properties are all implicated and altered by inflammation." P. 80. 

Under the head of preliminaries falls another question which 
some are fond of debating, namely, whether the healing process 
be a process of inflammation. Mr Travers argues against the 
idea maintained by the late Dr Macartney and some other emi-> 
nent authorities, who refuse to recognise the healing process as 
an inflammation. To us the question appears to be a dispute 
about words. It is at present at least merely a question whether 
the word inflammation shall Iiave a larger or smaller extent of 
signification. The larger use of the term seems warrantable, 
because the facts ascertained correspond with the idea that the 
healing process, and what is called by contrast spontaneous in^ 
flammation, are identical in character. 

The name which Mr Travers has bestowed on his work. The 
Physiology of Inflammation and the Healing Process, suggests 
another and very important view of this point. Why the phy- 
siology of inflammation ? one might say. What has physiology 
to do with inflammation ? What is pathology, if inflammation 



THE PHYSIOLOGY OF INFLAMMATION. 67 

be not a part of pathology ? In one sense Mr Travers might 
reply, Physiology, as standing in contrast to physical science, 
and exhibiting the laws of living nature under all possible cir- 
cumstances, must include pathology. But, doubtless, what led 
Mr Travers to adopt for liis work the title Physiology of 
Inflammation, was the influence of the Hunterian views of in- 
flammation over his thoughts, — those views which represent 
inflammation as an act or suite of acts designed to serve a pur- 
pose in the animal economy — a physiological provision without 
which death would result from the slightest accidents, while, 
during its shortened span, the body would be covered at innu- 
merable points with raw and irritable sores. 

According to the Hunterian views, the susceptibility of in- 
flammation in Uving parts is the reparative power ; inflammation 
is one of the oflSces of life — an occasional function called into 
activity when injury is inflicted. Such is the normal character 
of inflammation. But, like every function of the living body, it 
is liable to abnormal states, and these abnormal states are true 
states of disease. 

But besides bearing on the question whether the healing pro- 
cess be a process of inflammation, the view just taken may be 
used as a method of investigating the phenomena of inflammation. 
We are not prepared to aflSrm this to be the justest light in 
which the nature of inflammation can be investigated. Nor can 
we deny the tendency of this kind of analysis to lead into some 
errors in pathology. But when a due regard is paid to facts, 
and a proper discretion exercised over the inferences from them, 
we look on this mode of investigatioTi as perfectly sound, and of 
a kind to bring out some parts of the process which, by any other 
mode of inquiry, might escape observation; 

The grand difliculty in constructing a proper theory of inflam- 
mation undoubtedly is, to connect the causes with the phenomena 
which first arise, or with the dilatation of the capillaries and the 
stagnation of the blood. In the production of these, the first 
phenomena, it seems to be impossible to dispense with the agency 
of the nervous system. The isict on which these phenomena de- 
pend must be either in the aflfected capillaries themselves, or in 
the contained blood, or in both. For the dilated vessels must 
still be subject to the whole momentum of the mass of the blood, 
there being no obstacle interposed between them and that mass 
to mtercept the effect of its momentum. The contents, there- 
fore, of the dilated capillaries, when stagnant, are not stagnant 



58 THE PHYSIOLOGY OF INFLAMMATION. 

because no longer pressed forward by the momentum of the 
blood between them and the heart, but because that momentum 
is insufficient to overcome their present inertia. It seems certain 
that nervous filaments are suppUed to the coats of the capillaries ; 
and there is but one great law of nervous action, namely, that 
impressions made on the extremities of certain nervous filaments 
are succeeded by influences transmitted from the central organs, 
or the ganglionic centres, by which changes on the mechanical 
state of distant parts are brought about. It is therefore, at least, 
a probable inference, that when the cause of inflammation acts on 
the part to be aff'ected, the nerves give origin to those changes 
which constitute the first phenomena. The conclusion is here 
brought out without reference to final causes, or to the Hunterian 
method of investigation. But it would be easy to show that 
that method, though it could not teach us that the capillaries 
are supplied with nerves, might in so far lead us to the same 
conclusion, by pointing out that a process, involving complex 
purposes of design, must necessarily be dependent, like acts of 
instinct, on nerves, thereby inducing us to search for the nerves, 
if these had not been before discovered. 

What the nature of the change wrought by the nerves is, we 
do not at present propose to inquire. The subject is not so im- 
mediately suggested by the work before us as to warrant our 
entering on it at sufficient length. And we fear pathology is 
still far from the point of fixed knowledge on this subject. 

But there are several important subjects of inquiry towards 
a complete theory of inflammation, which should engage the 
attention of pathologists, or rather of physiologists, even while 
the nature and mode of production of the earUest phenomena 
are incomplete. Thus, it may be considered, if the distention 
of the capillaries and the accumulation of their contents have 
an object, — if the exudation of liquor sanguinis and then of red 
corpuscles bo the final purpose of this dilatation and stagnation, 
— and how far this state agrees with the other known states of 
vascular turgescence which precede increased deposition from 
the blood, — whether the mechanical force here manifestly ap- 
plied through the momentum of the mass of the blood to the 
dilated vessels and their contents be the sole cause of the exuda- 
tion, or only an assistance by which the effect of a vital act of 
transmission is increased. 

Again, it has to be determined how far the important pro- 
perties of tonicity and elasticity, first of the arterial trunk 



THE PHYSIOLOGY OF INFLAMMATION. 59 

feeding the affected part, and next of the arterial system at 
large, are acted on by the local obstruction. By what steps 
does the artery of the inflamed part become distended and 
convey more blood than usual ? Is this artery brought more 
into the condition of a rigid tube than in its healthy state ? — or 
does it still expand under the stroke of the yentricle, and is its 
elasticity increased proportionately with its distention, so as to 
enable it still to contract on its contents ? Or is the strength of 
its pulse independent of any actual expansion under the stroke 
of the heart, and is the blood transmitted through it by the 
direct impulse of the heart, without any contraction of its own 
walls? The whole subject of the motion of fluids through 
tubes with elastic walls requires revision. The conmion com- 
parison of the elasticity of the arteries to that of the air in the 
air-vessel of a fire-engine is wholly deceptive, — ^the cases are 
not parallel. 

Again, the natural motion of the blood in the capillaries 
requires to be better understood. Our facts are too much 
drawn from cold-blooded anim^ds ; the circulation of the Bat's 
wing is too little studied. The proportion of blood in the 
capillary system and the rate of its motion have hardly been 
computed. The mere inspection of its movement in the field 
of the microscope is quite fallacious, — ^the microscope multiplies 
the rate of motion in the same proportion in which it magnifies 
the moving bodies and the surfaces over which they move. 

Moreover, we cannot "tell whether the red corpuscles keep 
the middle of the stream by a principle of physics, or as the 
effect of vital influence. In short, we have not yet studied the 
physical laws applicable to the motion of such organic fluids as 
the blood, which are not true fluids, but fluids loaded with 
solid matter. 

Further, we know by Poiseuille's experiments that the mo- 
mentum of the blood is much the same all over the arterial 
trunks and even in the small arteries ; but what do we know of 
its momentum in the capillaries ? 

But we might go on to weariness with the enumeration of 
the points bearing on the theory of the phenomena of inflamma- 
tion which still require examination. We propose, therefore, 
at once to sum up this article with some account of what the 
work before us contains, and with some further extracts, to 
show the style in which Mr Travers treats the subject. 

The work is not of great extent. It is a duodecimo volume, 



60 THE PHYSIOLOGY OF INFLAMMATION. 

consisting of twelve chapters besides an introduction, in all 
occupying little more than 200 pages. His first chapter turns 
on preliminaries, from which we have already quoted one 
passage. The second chapter contains his microscopic observa^ 
tions on the effects, in the web of the frog's foot, resulting from 
the application of solution of common salt, of ammonia, and from 
an incised wound. In these observations he was assisted by- 
Professor Owen. In the seventh chapter he has given a table 
of the preparations — now in the Museum of the Royal College 
of Surgeons of England — made by the late Dr Todd of 
Brighton, to illustrate the progressive stages of the healing 
process. And in the ninth chapter, he has given the results of 
a repetition of Dr Todd's experiments by himself, with the 
assistance of the well-known microscopist Mr Quekett ; with 
this difference, that, instead of following Dr Todd's practice of 
killing a frog day after day to preserve a preparation of the 
appearance of the wounds at successive stages, he permitted each 
frog to live, to show, in the same individual, the successive stages 
of the healing process. We extract some passages from the 
digest of the phenomena developed in the healing process, with 
which the chapter terminates : — 

^^ Stasis or actual arrest of the circulation is a direct effect of local irrita- 
tion, more or less persistent according to tlie degree or shock. Thus, if 
unattended by injury to structure, recovery frona it restores the previous 
condition, whether inflammation be set up or not. Its local extent, like its 
duration, will be according to the amount of the irritation. The circula- 
tion is oscillatory at the verge of the stasis ; beyond this it is pretematurally 
slow ; and yet farther from the stationary centre it is, or appears to be, 
somewhat brisker than natural. The suddenness and completeness of the 
stasis determine the acuteness of the inflammation ; it is slowly formed and 
imperfect in what are termed congestive inflammations. 

" Contingent upon the stasis is the efiusion of serum, or of the liquor 
sanguinis, the one or the other according to the nature of the injury in- 
flicted, whether of function simply or of structure. If serum only be ef- 
fused, the inflammation, if any be present, admits of perfect resolution ; not 
so if the efi^usion be of the liquor sanguinis, holding the fibiine of the blood 
in solution. This is the distinction between the efi^usions of shock and of 
lesion, the nervous and vascular, the inflammatory and non-inflammatory 
oedema. The second results from a more considerable and prolonged action 
than the first, if both be the efl^ects of inflammation ; but whereas the 
aqueous effusion is often unattended by inflammation, the fibrinous effusion 
is characteristic and proper to it, whether with or without primary breach 
of texture." 

" The fibrine effused in a state of solution in the liquor sanguinis only 
becomes susceptible of oi^ganization, t. c. capable of permanent incorporation 
with the living solid, when separated from the other constituents of the 



THE PHYSIOLOGY OF INFLAMMATION. 61 

blood. It is incapable of oTganizaiion if effused in combination with ther 
blood-corpusclesy as in extravasation or hemorrhage." Pp. 160-162. 

" The efFosion of Uie liquor sanguinis from the arterial capillaries is the 
first change consequent upon inflammation, either with or without breach ; 
it is in either case limited to the extreme verge of vascular action^ or the 
boundary line of its arrest (complete stasis). In the act of coagulation 
upon the face and sides of the wound, the contained fibrine separates from 
the serous portion of the liquor sanguinis, and becomes a crust or mem- 
branaceous stratum covering in the wound at all points, the sections of blood- 
vessels, nerves, absorbents, &c. This^ then, forms the intermedium of 
vascular communication by anastomosis in cases of union by adhemon. It 
is an efiPusion entirely distinct from and subsequent to extravasation of 
blood, and does not take place until after the act of inflammation is estah- 
lished, when the coloured coagulum becomes detached." Pp. 162, 163. 

" The second act in the healing process is the separation of the lymph 
particle from the blood within the vessel. This is not seen until after some . 
time has elapsed, for it is not an immediate consequence of the stasis^ which 
may and does continually happen without this separation, or any efiusion 
of lymph, as in simple irritation or inflammation of a sound texture without 
deposit." Pp. 163, 164. 

These passages, we should remark, are not quite continuous 
with each other ; neither are those which follow. 

^ The elaboration of the organizable lymph appears to become perfected 
as it advances, confirming the practical observation, that wounds which heal 
slow heal sound. It is quite a mistake to suppose that, in wounds with loss 
of substance, the effusion of organizable fibrine constitutes the permanent 
material of the new solid. The first deposit effused with the liquor san- 
guinis is an amorphous exudation, and presents no such regular figure and 
arrangement as the lymph particle which has been separated within the 
vessel before deposit. They are, in truth, different in this respect : the 
first, or that which forms immediately on the receipt of an injury, and 
serves for the intermedium of organization in a close apposition of surfaces 
(being separated from the liquor sanguinis with which it is effused), would 
not serve as a base for the new solid ; it is soon absorbed, being only a tem- 
porary bond or adhesive layer in harmony with the parts, though serving 
the important purpose of consolidation by anastomosis of the contiguous 
vessels of opposite sides, or union by the first intention ; the second is not 
called for in mere divisions of substance, and is not ready if it were ; it re- 
quires a higher and long-continued inflammatory action ; it is a permanent, 
not a provisional or temporary mean of reparation, — a substantial addition 
of structure, not a mere conjunction of parts." P. 166. 

What Mr T. terms the lymph particle, is the colourless cor- 
puscle, concerning which so much discrepancy of opinion has of 
late existed. These colourless corpuscles exist at all times in 
the blood, but accumulate, under inflammation, in the capillaries, 
in which the blood moves slowly, or has begun to stagnate. We 
have given Mr T.'s views on the subject of the part assigned to 
the lymph particle in the healing process ; but our space does 



62 THE PHYSIOLOGY OF INFLAMMATION. 

Bot permit us to enter at present upon an examination of his 
opinion. 

Two quotations more must conclude our notice of this chapter. 

** To conclude : the inflammatoTy exudations are, — ^Ist, of serum ; 2dlyy 
of liquor sanguinis ; Sdly, of fibrine, or the material of new structure ; and 
the &bricator of the new TesEiel is the blood-corpuscle." P. 169. 

*^ The temporary stasis seems to be necessary to the exudation of liquor 
sanguinis, its continuance to that of the separated lymph particle ; and not 
less the graduated impulse of the returning circulation to the elimination 
of the blood-corpuscle in single globules for the fabrication of new vessels ; 
for if it were in mass (hemorrhi^) it would destroy instead of promoting 
organisation." P. 169. 

Besides the chapters already referred to, there is one on the 
local symptoms of inflammation, one on its constitutional symp- 
toms, two on the processes of inflammation, effusion, and adhe- 
sion, one on granulations and pus, one on ulcerative inflamma- 
tion, one on cicatrization, and the last on gangrenous inflamma- 
tion and gangrene. These chapters contain throughout many 
observations, which, did our limits permit, we would gladly 
quote for the benefit of our readers. We must, however, refer 
them to the book itself. 

It is impossible for a man who, like Mr Travers, is at once 
profoundly read, an original thinker, an industrious experimen- 
ter, and a practical surgeon, to write a book on inflammation 
which should not be of the highest interest. Yet we cannot 
promise that it will become very popular with the profession. 
It is not a book which one who runs may read. It requires to 
be studied to be understood. Amidst a great deal of clear state- 
ment and methodical dealing with the subject, there are occasional 
obscurities very discouraging to the reader. But we are sure if 
the book be read from end to end, no one will fail to carry away 
with him all that the author wishes to inculcate. 

The work, however, does not the less merit attention, when 
we consider the deservedly high reputation of the author, that 
some of his views do not coincide with those generally taught. 

There is no part of the whole subject of inflammation on 
which there exists so much difficulty and obscurity as the nature 
of suppuration and the origin of pus. And we have accordingly 
been much interested by the chapter before referred to on gra- 
nulation, pus, and suppurative inflammation. And yet we do 
not find it easy to pronounce a positive opinion on his views. 

^ The granulation is a mesh of the terminal loops of capillary pencils^ 
formed, as has been described, under the adhesive inflammation in tho 



THE PHYSIOLOGY OF INFLAMMATION. 63 

newly deposited fibrinous membrane coaUng the suifiice of tbe breach or 
cavity in the original solid/' P. 110. ^ The aspect of the suppniating 
membrane also varies to sach extent as scarcely to exhibit, in some cir- 
cumstances and situations, the granular form, e»g. upon the vralls of ab- 
scesses and upon the free surfaces of mucous and serous membranes ; but 
the fibrinous bed and the capillary loop of new formation, and a correspond- 
ing alteration of the pus-secreting surface from its normal state, will always 
be detected upon careful examination, being essential elements of the sup- 
purative process." P. 111. 

It will strike every one that what he says here is most doubt- 
ful as respects the suppurative inflammation of mucous mem* 
branes. It is quite true, as Dr Hodgkin says, ** that when the 
mucous membrane has been for some time pouring out a more or 
less puriform secretion, its surface, although no abrasion or ulcer- 
ation may have taken place, becomes irregular, from an infinite 
number of rounded elevations or granulations, which are generally 
extremely minute, but bear a close resemblance to those which 
are formed on the surface of a healing ulcer ;"* but still this 
does not carry conviction that pus is never thrown out by the 
mucous surface, without the previous deposit of coagulable lymph. 
Moreover, we find that Mr Travers modifies the view exhibited 
in the passage before quoted by some subsequent passages. The 
first passage, however, which we shall cite from his work, 
rather goes beyond that above referred to. 

^ If, upon careful inspection of the free sur&ce of mucous membrane 
secreting pus, no appearance exactly resembling granulation can be observed, 
the membrane is ^tered, t. e, raised and thickened by a deposit of hyper- 
vascular lymph in the interstitial or subjacent tissue." 

How much the following passage, nearer the end of the book, 
modifies the two which have been already cited on this subject, 
will be at once apparent. 

^ The open-mouthed follicles of the mucous membrane are equivalent to 
granulations, t . e, equally secrete pus, in lieu of their proper secretion under 
inflammation. This shows that the especial form of granulation is not in- 
dispensable to the secretion, though it is a form which the efiiised fibrine 
more or less afiects, when suppuration is set up." P. 171. 

We suspect that the last-quoted passage gives up the doctrine 
maintained in the previous part of the work, namely, that pus 
is a secretion performed by a temporary secreting apparatus 
produced by effused lymph, and that the granulation of open 
surfaces is the type of that peculiar gland. Nevertheless, the 
view taken by Mr Travers on the subject of the production of 

* Hodgkin*8 Lectures on Serous and Mucous Membranes, vol ii p. 28. 



64 THB PHYSIOLOGY OF INFLAMMATION. 

pus, deserves to be tried by farther experience before it is 
condemned. 

We shall close this article with a few short extracts from the 
chapter " On the effects of inflammation on the system," which, 
representing the ideas of a man of so great judgment and ex- 
perience as Mr Travers on the treatment of inflammation, can- 
not but be acceptable to our readers. 

^^ In the fever attending inflammation of the vital organs and their in- 
volucra and chambers, the free detraction of blood is one of the most im- 
portant points of treatment, and this whether inflammation results from 
injury or other causes. The life of the patient seems, in a great measure, 
contingent upon his power to bear, and his susceptibility of relief from the 
loss of blood— conditions which are not at variance— at first in larger and 
afterwards in smaller quantities." P. 57. 

'^ In inflammations, however originating, whether from injury or diseased 
habit, affecting the extremities, general bloodletting is seldom advisable, or 
even practicable with safety. From the part blood is taken, by various 
methods, with very great advantage in such cases." P. 57. 

** In visceral inflammation, venesection is indicated and warranted to the 
utmost extent that the powers of life will bear ; for here the mass of blood 
is so altered and spoiled for its proper healthy purposes, by the direct im- 
plication of the blood-making and blood-preparing organs in the disease, 
that relieving the system of its presence to the extent tiiat can be borne, is 
the main resource we possess for its preservation." P. 58. 

We fully agree with Mr Travers as to the imperative neces- 
sity for the detraction of blood " to the utmost extent that the 
powers of life will bear," but we hesitate to subscribe to the 
reason assigned in the above passage for the practice. 

" There are two false doctrines concerning blood-letting for inflammation, 
which cannot be too strongly condemned : the first anticipatory blood- 
letting, by which I mean, the large and repeated deti-action of blood before 

inflammation, being considered inevitable, has actually manifested itself 

on the hypothesis of starving the action, and thus rendering it tractable 

which is a direct attack on the vitality, and fatally perverts the action, if it 
do not destroy the resisting powers^f the system. The second, continuing 
the employment of the lancet so long as the last drawn blood exhibits the 
signs of inflammation, which, if drained to the last drop it would do ; or iu 
other words, not reflecting that there is a line beyond which the practice 
becomes destructive, instead of remedial ; and that there are many inflam- 
mations which do not admit of arrest by depletion, and upon which other 
modes of treatment are efficient for this end, even though not an ounce of 
blood be drawn." P. 59. 

With these remarks and quotations, we leave this book in the 
hands of our readers ; to such of them as have leisure for the 
study of so small a volume, we recommend it as full not only of 
descriptive knowledge, but also .of abundant food for speculative 
reflection. 



ANATOBIY AND PHYSIOLOGY. 65 



Part III— PERISCOPE. 



ANATOMY AND PHYSIOLOGY. 

Medicins at the present time appears to stand npon a yeiy doubtfiil basis ; 
its position being marked hj a great want of knowledge conceming the 
nature of disease. Correctly speaking, medicine has not yet become a 
scieDce. If this statement be untrue, why is it that doctrines such as those 
of homoeopathy and hydropathy, so opposed as they are to the received 
doctrines of our profession, are permitted to pursue their present progress- 
ive course unchallenged ! We say unchallenged, because it appears to us 
that all which has been written against these and other crude doctrines has 
not exposed in any one point the real nature of such errors. Why is this 
the case ! It is because medicine is not a branch of knowledge regulated 
and controlled by known general laws. If a person of fancy and genius 
gave forth to the world, with great eloquence and reasoning, a work in 
which he endeavoured to prove the correctness of the old belief that the 
earth is the centre of the universe, and at rest, and that the celestial orbs 
must all move in perfect circles and with a uniform motion, would not 
such a work be proved to be erroneous from the very nature of things ! And 
would not this proof be capable of being made so satisfactory to the most 
common mind, as to make that mind scoff at the powerful reasoning and 
great eloquence by which the newly resuscitated notions had been dressed 
up 1 We again ask the question, Why is this ! It is because the science 
of astronomy is regulated and controlled by known general principles. The 
physician is at the present time in the humiliating position of the boy in 
the theatre, who sees the scenery on the stage continually shifted, and with 
the shiftings differences in appearance, but who is entirely ignorant of the 
mechanism or mode by which these several changes are effected. In the 
same poation stands the physician ; — ^he enters the patient's room, — ^lie 
watches the countenance with anxious care, — ^he feels the pulse, and ob- 
serves the tongue, and then using these signs as we do the words of a lan- 
guage, he becomes acquainted with the ravages that are going on within. 
But what does he know of these ravages ! The principal parts of the cata- 
logue may be stated to be as follows : — A certain organ is diseased — ^the 
progress of the disease is learned — an abnormal action is going on, the effect 
of which will probably be a complete disorganization of the organ so diseased. 
This is all he knows, — at least all that he knows is of this character. He 
is acquainted with the effects merely ; the nature — the mechanism by 
which these effects have been produced, are to him, at present at least, as a 
sealed book. Thus it is that many baneful and truly fantastic hypotheses 
reign rampant for a while, until some new favourite of the same type steps 
in and knocks the now friendless theory from its former high position to rest 
in forgetfulness. Medicine as a science cannot now be advanced one step 
hy mere observation at the bedside, or by coarse anatomical dissections made 
in a large hall with large knives. Medicine can only now be advanced 
through the aid of the physiological anatomist and the organic chemist. On 



66 ON THE STRUCTURE OF THE NERVOUS SYSTEM. 

them, in the present day, depends the true advance of medicine. The fonner 
must, by careful observation and mechanical analysis of the phenomena of 
life and organized matter, acquaint us with the forms which nature gives 
to matter while producing beings, while developing them, and while retain- 
ing them in health. And the latter must, by his analytical and synthetical 
processes, reveal to us the laws which regulate them in the producing of 
those various forms with which the physiological anatomist has made us 
acquainted. For the fulfilment of these noble objects, men are required 
whose whole hearts are devoted to medicine as a science. 

We give these few remarks in our first number for the purpose of mak- 
ing our readers acquainted with the objects which we shall always have in 
view in the physiological department of the Periscope, namely, to endeavour 
to bring to bear upon the nature of disease all physiological, oi^nic, chemi- 
cal, and microscopic discoveries. 



On the Structure, Relations, and Functions of the Nervous System, 

There is contained in the last published part of the Philosophical Transac- 
tions of the Royal Society of London a very admirable paper, by Mr New- 
port, upon the structure and functions of the nervous system, and on the 
existence of a complete circulation of the blood in vessels, in some of the 
articulata. We intend to give here some extracts from that portion of 
the paper which relates to the nervous system, as it illustrates the functions 
of a certain portion of that system in man. 

^' In all the articulata two modes of development of the nervous system are 
in operation in the same animal : — first, that oi growth, or simple extension 
and enlargement of each individual part ; next, that of aggregation, or the union 
of two or more parts to form particular divisions or regions of the body. The 
brain of the myriapod or centipede is formed by the aggregation of separate 
ganglia placed above the oesophagus. The first pair of ganglia are always 
the smfdlest, and give origin on their front to the nerves of the antennae ; 
the second pair immediately behind them constitute the organs of volition, 
and represent the brain of the vertebrata. They are attached at their 
under and external surface to the central nervous cord by two bands of 
nervous matter, which are prolonged downwards on each side of the pha- 
rynx, and constitute the crura cerebri.** 

"Structure of the Cord, — The cordis a compound structure, composed, first, 
of two distinct longitudinal columns of fibres, which are quite distinct from 
each other, although closely proximating together ; secondly, of fibres that 
run transversely through the cord ; and, thirdly, of fibres that run longi* 
tudinally in part of their coui'se at the side of the cord, and enter into the 
composition of all the nerves from the ganglia. These fibres I shall desig- 
nate the fibres of reinforcement of the cord." 

*' The Superior Longitudinal or Aganglionic Set of Fibres. — These fibres I 
formerly described as the motor tract. The function of volition seems still 
to be accorded to them by Valentin, Carpenter, and Baly. They extend 
as a separate fasciculus along the upper surface of the cord. On a cursory 
inspection, this tract of nervous matter does not appear to give oflF any 
branches, but seems to pursue its course uninterruptedly along the whole 
length of the cord. It does not indeed give off filaments to the nerves from 
a ganglion while passing over that swelling, but immediately the fasciculus 
has passed over the ganglion, it gives off filaments that proceed to the nerves 
of the next ganglion." 



I 



ON TH£ STBUCTURB OF THE NE&VOUS SYSTEM. 67 

" Inferior LongitudiTial or Ganglkmc Set of Fibres of the Cord, — ^This por- 
lioii of the ooid affords many inteiesUng consideiations. It is placed ex- 
letly as in insects, on the under sorfiEbce. It is formed of a longitudinal 
leiies of fibres^ like the upper tracts firmn which it is divided by some of the 
ibres tbat pass transyersely through the cord. There is one £ust of great 
Aiportance as r^ards this gaoglionic series of fibres. Almost the whole of 
lie fibres of which it ib composed are traceable directly through each en- 
vgement of the cord, which they mainly assist to form. At the interior 
part of each enlargement the diameter of each fibre, or fasciculus of fibres, 
appears to be slightly increased, and its structure becomes more softened 
and delicate." 

. ^ These are the structures to which I formerly assigned the function of 
Volnntary motion and sensation, and to which I am still inclined to believe 
they minister, since the fibres of which both are composed are traeeabk to 
flie crura and brain.'' 

*^ Those fibres of the cord which seem to be independent of the sets just 
leseribed, and which do not appear to have any direct communication with 
the great seat of sensation and Toliti<»], the brain, are of two kinds^ 
^ vhieh may justly be n^j;arded as innoluntary in their functions. The first 
i. these ace the eommieeural fibres which pass through the gauglia ; and 
; he second, or those which have hitherto been undescribed, and which form 
he sides of the cord in the interspace between the ganglia, the fbree of 
wtforeement of the eord*^ 
'* TkeFUnwofBemforeementofiheCord,'--'The9dhhTes£[>TmihelB^^^ 
^ lioBs of the whole nervous cord of the body, and enter into the composition 
I If all the nerves. They constitute, as it were, circles of nervous oom- 
vmnication between two nerves that originate from the cord at a greater 
I m less distance, and form part of the cord in the interval between these 
' ienres, and bear the same relation to the s^:m^ts individually which the 
loid itself does to the whole body. They form a part of the nervous trunks 
irhich come off from its aganglionic tract, as well as of those which pro- 
teed from the ganglionic tract. In this manner these fibres of rein- 
feieement connect all the nerves of the cord on one side of the body, as 
te correqionding fibres do on the opposite side. They form as it were 
Vmble, treble, or quadruple circles, one within the other. Thus the fibres 
Sai pass inwards along one nerve, may proceed along the cord to pass out- 
"uds again on the front of a seccmd, a third, or a fourth, thus linking the 
Kgrnents in one continued series of nervous communications, independent 
of the brain. But these communications exist only between nerves on 
the same side of the body, and not between those on the opposite. The com- 
miuural nerves connect the opposite sides of each individual segment, as 
those of reinforcement do the same sides of two separate s^;ments." 

** Every nerve from a ganglionic enlargement of the cord is thus composed 
of four sete of fibres, an upper and an under one, which communicate with 
the cephalic ganglia ; a transveise or oommiesuraly that communicates only 
with the corresponding nerves on the opposite side of the body ; and a lateral 
set, that communicates only with the nerves on the same side of the body. 
The fanctions of the two last-mentioned sets must be regarded only as 
leflex ; entirely independent of sensation, but capable of being excited into 
action by external causes.** 

''The existence of these lateral fibres in the cord may now fuUy explain 
the reflected movement of parts anterior or posterior to an irritated limb 
on the same side of the body, as the conuuifisnral ones do the movements 



68 ON THE STRUCTURE OF THE NERVOUS SYSTEM. 

of parts on the side opposite to that which is irritated. The presence of 
these fibres in the cord of insects I had long suspected, from the cnrred 
direction of the fibres that bound the ganglia, and from that of the origins 
of the nerves from the aganglionic tract, as figured in my former paper ; 
and although I had communicated this opinion to a friend seyeral years 
ago, I have never until recently been able to satisfy myself of its correctness." 

^^ This uncertainty of the existence of any structure in the cord that seemed 
sufficient to explain the reflected movements on the same side of the body, 
independent of the brain and the nerves of volition and sensation, long 
obliged me to withhold my assent to the doctrines now received respecting 
these phenomena." 

^^ Although the fibres that pass transversely through ganglia might explain 
the effect produced on one side of the body by the irritation of a correspond- 
ing part on the other, there seemed no anatomical structure to account for 
the movements of distant parts, anterior or posterior to a given point, on 
the same side, if the doctrine long received, that each fibre is endowed with 
but one special function, were correct. Now, therefore, that we find an 
anatomical structure in the cord that seems to account for these pheno-> 
mena, it ought in justice to be stated, that Dr Hall, to whom is due the high 
credit of collecting, comparing, and arranging in one system numerous facts 
connected with the reflected movements of animals, as observed by Whytt, 
Blane, and others, and also by himself, — adopting the principle established 
by our distinguished physiologist. Sir Charles Bell, that every nervous fibre 
is continued unbroken from i^ origin to its termination, and is capable of 
ministering only to one special function,— -conceived the necessity for the 
existence of special nerves for the reflected movements." 
{To be continued.) 



SURGERY. 

(holscheb's hannoversche annalen.) 

Memoir on the Diagnosis of Cancer of the Eyelids. By Dr Canstatt of 
Ansbach (now Professor at Erlangen). 

A SERIES of observations collected at the Ophthalmic Clinic of M. Sichel, 
whose assistant he was for a considerable time, has led Dr Ch. Canstatt to 
the following conclusions on the diagnosb of cancer of the eyelids. 

Progress of the Disease. — The progress of this disease presents numerous 
varieties ; but it appears that its course is much slower in the eyelids than 
in any other region of the body. Often years elapse without the soirrhus 
gaining either in breadth or in depth. However, no means either pharma- 
ceutical or surgical has the power of repressing or checking it. Ou the 
contrary, every attempt of this kind ends in hastening the transformation 
of scirrhus into open cancer. The stationary state of the ulcers of the lids 
has been already pointed out by Jacob as a sign of their cancerous nature. 

Original Seat of Cancer of the Eyelids. — Most frequently the original seat 
is in the palpebral conjunctiva, and from thence it attacks the skhi on tha 
other side of the palpebral edge. Sometimes the skin is affected first. The 
affection may be considered as glandular scirrhus when it commences in 
the lachrymal caruncle. 

The frequency of cancerous ulcerations at the Internal angle of the eye 



CANCER OF THE EYELIDS. 69 

Is very remarkable. This fact is e^lained by the use of this angle, which 
Benres as a receptacle tbr the difierent secretions of the conjunctira and of 
the glands of the lids. 

Primary Affet^itmt iMch give rise to Cancerous Ulcerations. — ^It is very 
rue to see a tabercular excrescence of the conjunctiva degenerate into 
cancer. Most commonly an ulcer, of at first a simple appearance, degene^ 
rates, either in consequence of an irritating treatment, or under the in- 
fluence of an unhealthy constitution of the patient. An advanced age, 
want of cleanliness, or the cessation of the catamenia, exercise a well-marked 
influence on the modification of the character of these ulcers. The cuta- 
neous scirrhus of the eyelid is frequently developed, as in other regions of 
the body, as a consequence of a tumour which only differs from an ordinary 
wart in the lancinating pains of which it is sometimes the seat. On this 
account, it is necessary to extirpate excrescences of tliis nature as soon as 
ihey make their appearance. The ravages of cancer of the eyelids may ex- 
tend themselves in a firightful manner. Sometimes the sufferings of the 
patient are terminated by death, in consequence of an affection of the bones 
and of the membranes of the brain. 

Appearance of the Cancerous Ulcer of the Eyelids. — ^The bottom of the 
ulcer, often foul, is covered by crusts which are detached spontaneously, or 
are torn off by the patient, and which may give rise to hemorrhages. These 
cmsts gun insensibly in breadth whilst the ulcer becomes deeper. Often 
all the parts capable of carcinomatous degeneration are transformed into 
tubercular masses before the ulcer becomes open ; but this when once esta* 
blished causes the most rapid destruction. Sometimes the invasion of the 
neighbouring parts takes place by paroxysms of exacerbation, after the dis- 
ease has been for a certain time stationary, and even when hopes of a speedy 
cure have been entertained. The skin is rarely inflamed far beyond the 
limits of the ulcer, and does not undergo any scirrhous modification. Rarely 
are these fungous excrescences which abound in affections of this nature, 
having their seat in other regions, seen to elevate themselves from the bot- 
tom of a cancerous ulcer of the eyelids. This is the more remarkable, as 
in the eyelids the surface of the ulcer is exposed to a continual irritation 
fix)m the contact of the air and the secretions of the eye. Hemorrhage sel- 
dom complicates these ulcers, which do not furnish such a sanies and such 
a tainted secretion as an open cancer does in other regions of the body. 

Practical Conclusions. — ^Every ulcer of the eyelids ought to be operated 
on at an early period, which presents a suspicious character, if, not yielding 
to rational treatment, it remains stationary or makes fresh progress. The 
operation, when performed in time, permits the hope of a perfect cure of 
cancer of the eyelids ; whilst, if temporized with, it threatens, during its 
existence, not only one of the most important organs, but even life itself. 
The opinion of M. Canstatt is conformable to that of Jacob, who declares 
that every therapeutic agent other than the employment of the bistoury, 
ought not to be applied for the treatment of cancer of the eyelids. Caute- 
rization, especially by means of the arsenical paste, which is justly recom- 
mended for the treatment of cutaneous cancer in other parts, as the nose, 
lips, &c., ought not to be practised, except in an extremely cautious manner, 
in the case of cancer of the eyelids. Not only does the danger of its second- 
ary action upon the eye contra-indicate its employment, but besides, expe- 
rience does not appear to have verified in this case the success due to it in 
the same affection when it has its seat in other parts of the body. 

Annales d^Oculistique^ Fevrier 1844, 



70 NEW PREPARATIONS OF IRON. 

MATERIA MEDICA AND DIETETICS. 

On the Preparations of Iron recently introduced into Practice. 

The preparations of iron are most deservedly in high esteem with practical 
medical men. The reputation of these preparations, in the treatment of 
diseases, has prohahly varied less for a long time past than that of most 
remedies of similar pretensions. There are, indeed, some indications of 
their having heen held for a time, since the commencement of this cen* 
tury, in a degree of suspicion with a part at least of the profession. And 
this suspicion seems to have arisen from their well-known power of acting 
as a stimulus to the vascular system — of increasing the force and frequency 
of the heart's action, — a property which was naturally enough thought to be 
incompatible with Iheir use in any chronic disease, where by possibility 
there might be inflammatory action secretly going on. 

But it seems now well established that there are chronic diseases attended 
with some degree of the inflammatory process, for example, chronic inflamma* 
tion of the mucous membranes, chronic diarrhoea, chronic dysentery, enlarge- 
ment of the liver or spleen, and ulcerations of the surface, in which those con- 
ditions are present that determine the utility of the preparations of iron. 
Besides, it was more the practice some years back than it is now to describe 
morbid alterations of tissue, such as so often characterize chronic diseases^ to 
inflammatory action. And if the recent introduction of the term diseased 
nutrition, to represent a part of the morbid agency in the production of 
textural alterations, before referred to inflammatory action, has been of no 
other use, it has at least left us more free to observe the effects of remedies 
on nmny chronic diseases, without the bias given to the mind by the ideas 
which inflammation cannot but call up. 

As respects the preparations of iron, however, in diseases generally, the 
risk at present is, from the universal attention paid to them, that their use 
will be carried beyond just bounds^ rather than that they shall be employed 
less than they deserve. 

And yet the indications for the use of iron in diseases have always been 
tolerably simple, and perhaps it is not premature to pronounce that these 
are already becoming still more simple tiian before. We refer to the exact 
evidence recently brought forward of what has been conjectured for many 
years past, namely, that iron used as a remedy goes directly to the nutrition 
of the blood, when the blood has fallen into an impoverished state. On 
this subject the memoir of Andral and Gavarret is highly interesting, as 
well as Andral's more recent little work entitled '^ Hematologic." 

It is hardly too speculative, when we look to the facts detailed in the 
memoirs just referred to, to represent the state of the system which calls 
for the use of iron in the following manner : The iron of the blood, in the 
healthy state of the system, is drawn from the organic matters containing it 
employed as food ; but in certain states of ill health the nutritive powers 
become inadequate to extract a sufficiency of iron from the ordinary food, 
for the maintenance of the blood in its perfect state ; while, if iron be given 
in the mineral state, the blood becomes restored more or less quickly to a 
healthy constitution. Thus, then, under this view, iron becomes an ali- 
ment rather than a medicine ; or, like common salt and water, it is an ali- 
ment from the mineral kingdom. 

Hence, besides the old indications for the employment of iron drawn 
from the languor of the circulation, the inactivity of the respiratory acts, 
and the depression of the nervous system, we obtain in addition the im- 
poverished state of the blood or the proportionate deficiency of the red 



NEW PREPARATIONS OF IRON. 71 

corpnsdes, — a deficiency which may be ascertained with or without the use 
of the microscope. The same view affords a satisfactory rationale of the 
difference between the efiects of iron as a stimulant on the living system 
and those of such stimulants as alcohol, opium, and the like. The latter 
agents, like iron, increase the force of the circulation, the activity of the 
respiratory acts, and the enei]f!;y of the nervous system, while digestion, 
secretion, and absorption, participate in the general excitement, and the 
whole system feels a fresh tone. But these effects are short-lived ; there 
is expended on them much of the ordinary resources destined to maintain 
the body in vigour for some time to come, and hence, present exhaustion 
must ensue. There is a collapse of the system, marked by languor of the 
circulation, deficiency of respiration, abatement of the healthy vigour of 
secretion, and depression of the muscular tone. 

And the reason is, because the last-named stimulants possess little or no 
nutritive property. The excitement they produce is necessarily, therefore, 
a process of exhaustion ; unless, indeed, the system has previously fallen 
below its healthy standard, in which case such stimulants act the part of 
permanent tonics, by bringing the functions of maintenance nearer to the 
level of healthy vigour. But the preparations of iron, under the view above 
referred to, not only stimulate, but at the same time supply to the blood the 
means of sustaining the expenditure of substance produced by their stimulus. 

Bat enough of these generalities : we propose to give a short notice of the 
preparations of iron recently brought into use. 

Notwithstanding the difficulty of preventing the protosalts of iron from 
passing spontaneously into the corresponding persalts, a very general belief 
has sprung up that the former are of greater utility in a medicinal point of 
view than the latter. It is true that the rust of iron and the old precipitated 
carbonate are known by long experience to be beneficial in diseases, and it 
is equally certain that the discovery of chemists that they are not carbon- 
ates cannot invalidate their claim to this title* Why then, it may be asked, 
take so much pains to exhibit iron in the form of a true carbonate, if there 
be no experience till of late of its utility, while there is the experience of 
many years in favour of the sesquioxide into which the carbonates spon-* 
taneously pass ! But since it is quite possible that, while the sesquioxide 
is useful, the true carbonate may be more useful, let us consider on what 
ground of experience the latter persuasion rests. The antihectic mixture 
of Griffiths, represented officinally by the compound mixture of iron and 
by the compound iron pills, has, from an early period, enjoyed a high re- 
putation among practical men, in spite of the efforts of chemists and phar- 
maoeutistsy who rest their opinions on theory too little qualified by ex- 
perience in the actual treatment of diseases, to banish it as unscientific. 

It is now found that this supposed unscientific mixture is the only form 
in which we have any long experience of the medicinal effects of iron in 
the state of carbonate. And hence arises a probability that the reputation 
of the compound iron mixture in diseases depends on the iron being in the 
state of carbonate of the protoxide. It is retained in that form by the 
presence of sugar, whichj according to the singular discovery of the Greiman 
chemist Klauer, prevents the decomposition of the carbonate of the pro- 
toxide by preventing the protoxide from passing into the state of sesquioxide. 
The same statement applies even more forcibly to the solid form of the 
same combination, the compound iron pills, or Griffith's pills. 

Previous to the announcement of Klauer's discovery, Dr Clark of Aber- 
deen had proposed to preserve the precipitated carbonate from passing into 
sesquioxide by avoiding any drying of it, and making it at once, after 



72 NEW PREPARATIONS OF IRON. 

merely sqaeezing it, into an electuary with sngar and aromatiiss. And Dr 
Chi'istiaon had also preyiouBly observed, that the iron of this electuary had 
not lost its carbonic acid even when it became quite dry. 

In the first English edition of the Edinburgh Pharmacopeia, advantage 
was taken of Klauer*s discovery, and a saccharine carbonate of iron intro- 
duced. This saccharine carbonate is found to be a mixture of the carbonate, 
of the protoxide, and the sesquioxide. A pill of the saccharine carbonate 
was introduced at the same time. Many practitioners have of late adopted 
the use of the carbonate of iron made extemporaneously at the moment of 
being taken. The formule for this purpose contain some soluble salt of 
iron, with an alkaline carbonate, as the solution of the sulphate with the 
carbonate of soda. From 8 grains of sulphate of iron, and 10 grains of 
carbonate of soda in solution, an effervescing draught is obtained, contain- 
ing ten grains of carbonate of iron. The tincture of the muriate is also used 
in the same way with an alkaline carbonate. Besides these preparations, 
the sulphate and the black oxide contain iron in the state of protoxide, 
combined in the latter with the sesquioxide. Or the London Pharmacopeia 
contains three preparations in which the iron is In the state of protoxide, 
namely, the mistuia ferri composita, the pilulie fern composits, and 
the sulphate of iron ; while the Edinburgh Pharmacopeia contains the 
same, with the exception of the piluls ferri composite, and has be- 
sides the saccharine carbonate, the pills of the saccharine carbonate, and 
the black oxide, now made by precipitation after the formula of Wohler. 

More recently it has been found that sugar has also the effect of pre- 
serving the protiodide of iron from passing into the periodide. And this 
discovery has been taken advantage of in tho new preparation of the Edin- 
burgh Pharmacopeia, the ferri iodidi syrupus. 

The most important new officinal preparation in which the iron is in the 
state of sesquioxide, is the hydrated sesquioxide, termed, rather unhappily 
we think, by the Edinburgh College, Ferrugo. This is the substance r&* 
commended as an antidote to arsenic, and it will most probably be found to 
supersede the common rust and the sesquioxide formed from the precipitated 
carbonate. 

Besides these officinal preparations, many others have been recommended 
of late, and some have come into use. 

The following table includes those more worthy of notice : — 

Dose. 

Ferri bromidum, • . * • . gr, iii. to gr. viii. 

Pilulae ferri bromidi, gr. i. in each. 

Ferri citras, gr. v. to gr. viii. 

Ferri ammonio-citras, . . , , , gr. v. to gr. viii, 

Ferri et Quine citras, gr. iii. to gr. vi. 

Aqua chalybeata (citrate of iron in water charged 
with carbonic acid and flavoured with aromatics), ^ii. 

Ferri potassio-citras gr. v. to gr. viii. 

Liquor ferri potassio-citratis. 

Ferri tinctura aurantiaca (iron filings^ SeviUe 

oranges, Madeira, &c.), . . . . 3i. to §ss. 

Ferri lactas, gr. vi. to gr. xii. in the day. 

Ferri lactatis syrupus. 

Ferri lactatis trochisci. 

Ferri ammonio-tartras, , , , . gr. v. to gr. viii, 

Ferri tannatis syrupus. 

Ferri con&ctio composita, .... gss. 



NBW PREPARATIONS OF IRON. 73 

The bromide of iron is deliquescent and very soluble. The dose is from 
8 to 8 grains. The pills are made with a g. s, of extract of liquorice, each 
contaimng one grain of bromide. Their use is against glandular enlarge- 
mentfl^ hypertrophy of the uterus,* &c. 

. The citrate and ammonio-citrate of iron have been met with in the shops 
for some time« The citrate is permanent in air, sparingly soluble in water, 
very soluble in boiling water, and the solution reddens litmus>paper. The 
ammonio-citrate is deliquescent, soluble in cold water, neutral to test-paper. 
The citrate is made by saturating a hot solution of citric acid with moist 
hydrated sesquioxide of iron ; cmd the ammonio-citrate is made by adding 
enough of aqua ammonis to the same solution to render it neutral. 

The citrate of iron and quinine is made by mixing 4 parts of citrate of 
iron with 1 part of citrate of quinine. The citrate of quinine is made by 
dissolving pure quinine in a solution of citric acid. 

The ammonio-citrate, as soluble, is preferable to the citrate. The dose of 
either is from 5 to 8 grains. The ammonio-citrate should be given in solu- 
tion. The dose of the citrate of iron and quinine is from 3 to 6 grains. 
The form of pill answers best for this medicine. The uses of these prepara- 
tions are much the same as those of the tartrate. 

The aqua chalybeata, made by Bewley & Evans of Dublin, contains 13 
grains of citrate of iron in 6 oz. The dose is 2 oz. two or three times Srday. 

The tinctura ferri aurantiaca is contained in the Wirtemberg Pharma- 
copeia. It is an agreeable preparation, the dose being from one drachm to 
halfan ouncet. 

The ferri potassio-citras and its syrup are recommended by Dr Todd, and 
the mode of preparing them may be seen in the Lancet, 10th September 
1842, p. 822. 

The lactate of iron contains the protoxide. It is met with in small aci- 
colar greenish prisms, or in powder of a pale green colour. It contains 3 
equivalents of water of crystallization. It is sparingly soluble, and during 
solution passes into a higher state of oxidation. It is made by adding iron- 
filings to lactic acid. The syrup and lozenges are made on the common 
plan. The dose of lactate of iron is from 6 to 12 grains in 24 hours. Use 
in chlorotic diseases, atonic amenorrhoea,:^ &c. 

The syrup of tannate of iron is made from citrate Of iron by adding sim- 
ple syrup, syrup of vinegar, and extract of galls. The iron is said to be in 
the state of protoxide.§ 

The ferri ammonio-tartras occurs in brilliant scales, semi-transparent, and 
of a reddish brown colour. It is soluble in cold water. It consists of one 
equivalent of tartrate of protoxide of iron, one equivalent of tartrate of 
ammonia^ and four of water. It is made by adding hydrated sesquioxide 
of iron to a solution of tartrate of ammonia. It is permanent in composi- 
tion, and is given to the extent of from 5 to 8 grains, in powder, 
pill, or solution. It is recommended chiefly in derangements of the 
uterine organs. || 

• See Neligan, Conspectus of the Pharmacopeias. 

t See Medical Times, 11 th March 1843, p. 386. London and Edinburgh 
Journal of Med. Science, January 1843. Neligan, Conspectus of the Phar- 
macopeias. 

X Memoir by MM. Oelis and Coute ; also Medico-Chirurgical Review, October 
1840, p. 511 ; and Neligan, Conspectus of Pharmacopeias. 

§ See Medical Times, 11th March 1843. 

i) See Procter in American Journal of Pharmacy ; also Neligan*8 M&t. Med. p. 359. 

K 



74 TREATMENT OF ACUTE RHEUMATISM. 

The confectio ferri composita, made aooording to a formula given by Mr 
Heathcote of Gosport, contains clinkers, the scorie got from the blacksmith's 
shop. These appear from several accounts published of late years to have 
been long a popular remedy. Mr Heathcote says that they are much used 
in Bath under this form. 

Take of clinkers reduced to an impalpable powder, 8 oz. ; carbonate of 
magnesia, ^ oz. ; powdered ginger, 1 drachm ; treacle, a sufficient quantity ; 
make an electuary ; ^ oz. for a dose. 



PATHOLOGY AND PRACTICE OF MEDICINE. 

On the Treatment of Acute Rheumatism. 

The number of remedies proposed for the treatment of any disease is usu- 
ally in proportion to its obstinacy ; and, accordingly, while innumerable 
cures have been recommended in acute rheumatism, it is a disease which in 
many cases baffles our art. When we examine the various authorities for 
its treatment, we are struck, not only with the multitude of remedies pro- 
posed, but with their conflicting character ; and we find that, while one 
practitioner extols his prescription as curing almost every case, another 
pronounces it utterly valueless. In Paris, the subject seems to have attract- 
ed much attention, and various papers have of late appeared in the different 
journals, consisting of clinical observations on particular remedies. One of 
these, by M. Martin Solon, on the use of nitrate of potass, we condensed for 
the 5th number of the Scottish and North of England Gazette ; and we are 
induced to return to the subject by the publication in the " Archives Gene- 
rales de Medecine " of two papers by M. Monneret, — ^the one containing his 
experience of the employment of sulphate of quinine, the other recording 
the effects of tincture of colchicum, nitrate of potass, and blood-letting. A 
valuable resume of the various remedies employed, in rheumatism has been 
recently given by Dr Cowan in the Provincial Medical Journal, and from 
these sources we have derived much assistance in drawing up the following 
abstract. The various methods of treatment employed may be summarily 
comprehended under five heads : 1st, Pure Antiphlogistic Treatment ; 2dy 
Stimulant Sudorific ; Sd, Pure Stimulant ; 4th, Alterative ; 5th, Specific. 

!«/, Pure Antiphlogistic Treatment. — The principal remedial means com- 
prehended under this head are blood-letting and free purgation. Sydenliam 
was a decided advocate for blood-letting, recommending ten ounces to be 
abstracted every second day for four or five times. StoU, Sir John Pringle, 
and Cullen, were also advocates for its employment. Dr Fowler has some 
interesting observations on the effects of blood-letting in this disease. He 
employed it in 41 out of 87 cases, with the following results : Cured, 3 ; 
much relieved, 7 ; moderately relieved, 7 ; little relieved, 20 ; not bene- 
fited, 4. 

We find that Dr Fordyce was forced by experience to abandon blood- 
letting ; and Herberden informs us that copious blood-lettings are unsuitable 
to the majority of persons in rheumatism. The consequence has been, that 
blood-letting fell into comparative desuetude, until its employment was re- 
vived in modem times. Bouillaud is the most decided and uncompromising 
advocate for its employment that has ever appeared, and has pushed it with a 
vigour which, even in Edinburgh^ is startling. " The true specific," he ob- 
serves^ ^ of acute articular rheumatism is blood-letting ; its quinine, if the 



TREATMENT OF ACUTE RHEUMATISM. 75 

expression is allowable, is the antiphlogistic system, and bleeding is the 
prince of antiphlogistics." 

The patient is on admission bled to sixteen or from that to twenty-four 
ounces. Next day bled twice to sixteen ounces, and to amuse him between 
the bleedings, cupping or leeching is practised, from twelve to twenty 
ounces being thus abstracted locally. On the third day there is but one 
bleeding and one cupping. On the fourth, unless cured, bled again. On 
the fiffch, if the disease has not ceased, another blood-letting. The medium 
quantity of blood taken from vigorous subjects in a violent case is from four 
to five pounds. In some cases the abstraction of six, seven, or eight pounds 
may be demanded.* 

Dr Craigie, a decided advocate for blood-letting, states, '* that in order to 
be beneficial, it ought to be performed early in the disease, and carried to a 
considerable extent. * * * * It should be carried at first to 20, or 26, 
or do ounces at once, if possible, and within twenty-four hours to as much 
more."t 

On the treatment of rheumatism by blood-letting Dr Alison remarks, 
^that large and repeated blood-lettings in the beginning of rheumatism 
increase the risk of metastasis to the heart." | Dr Hope, in recording the 
experience of 200 cases, in reference to the "bleedingplan," writes as follows :§ 
" From ten to twenty years ago, this and the diaphoretic plan were in full 
vogue, especially in Scotland ; and I saw them carried to their maximum 
in the Edinburgh Infirmary during a residence of two years in that institu- 
tion. Now, many cases, I admit, were promptly and effectually cured — even 
annihilated at once — ^by the antiphlogistic plan ; but in many others, active 
bleeding was carried to the very last ounce that could be drawn, yet the 
enemy clung to the joints with a chronic grasp, and proceeded triumphant 
in his crippling career. Add the pale emaciated frame and the slow con- 
valescence, sometimes of two or three months' duration, and, too often, I 
fear, the permanently shattered constitution," &c. 

The following is the result of the experience of M. Monneret on the effect 
of blood-letting in 19 cases of acute rheumatism. In all these cases the 
blood-letting was practised with decision, — at least three general blood-let- 
tings being prescribed during the first four days, with two cuppings from 
the inflamed joints and the prsecordial region. The activity of the treat- 
ment stopped a little short of that recommended by Bouillaud. 

When the blood-letting was to prove beneficial, the pulse gradually fell, 
the temperature of the skin diminishing at the same time. In other cases 
the pulse would fall suddenly, while the temperature of the skin remained 
above the natural standard ; in these, the pulse would again rise, and the 
pains return with redoubled intensity, either in the joints already afiected 
or in others. 

When the pains are not relieved in the first four or five-days, we must 
not expect that the blood-letting will prove a radical cure, and if had re- 
course to after this, it appears to weaken the patient, and to produce a state 
of anemia unfavourable to ultimate cure. In such cases M. Monneret has ^ 
observed ** bruits de soufile " in the large vessels and sometimes in the heart, ' 
abundant sweating, vigilance, fulness and frequency of the pulse. The 

• See Nouvelles Recherches sur le Rheumatisme, Ac, par J. Bouillaud, p. 133. 

t Craigie, Practice of Physic, vol. ii. p. 664. 

X Cyc Prac. Med. Hist, of Med., part xxiv. p. 45. 

§ Med. Gazette, vol. xix. p. 814. 



76 TREATMENT OF ACUTE RHEVMATISAf. 

pains, instead of disappearing^ flit from one joint to another, or obstinately 
locate themselves in the ones first attacked. 

These patients become tedious convalescents^ often remaining two or three 
months in hospital. 

Nor is the chlorotic state, with its gastralgic and neuralgic pains, the 
only danger to which such patients are exposed ; but it seems to pave the 
way for other diseases, induced doubtless by individual predisposition. 
Sloughing over the sacrum, severe and fatal pneumonia, white swelling,' 
chronic enlargement of the joints, have all occurred in patients largely bled. 

The following are the conclusions at which M. Monneret arrives : — 

1st, That moderate blood-letting may have a beneficial effect in the treat- 
ment of acute rheumatism, if practised at the commencement of the disease, 
especially during the first four days ; but that after this period it can only 
weaken the patient, and retard the curative efforts of nature. 

2d, That the cases where blood-letting was most beneficial were those in 
which it was employed early, and carried to a considerable extent in a short 
time, 

3d, That although the beneficial effects of blood-letting so practised were 
far from being constant, yet that they appeared more satis&ctory than those 
cases in which smaller blood-lettings were resorted to at intervals through- 
out the whole course of the disease. 

Purgatives hold the place next in importance in the antiphlogiBtie 
treatment, and they have been freely used in the treatment of rheumatism. 
*^ Almost all practitioners," observes Dr Johnson, ** recommend cathartics 
in acute rheumatbro, on the principle of detracting fiwm the general 
circulation through the channel of the intestinal canal, thus reducing 
vascular action."* On the same subject, Dr Barlow recommends, after 
the use of the lancet, « to purge freely the stomach and boweWt So 
convinced are some practitioners of the efficacy of purgatives, that they 
attribute the benefit of certain remedies almost entirely to their cathartic 
properties. Of colchicum, for example, Dr Eliotson states, that it " generally 
does no good till it purges, and when once it purges the patient thoroughly 
the disease usually gives way. J Dr Craigie also speaks of the « benefit 
resulting from the use of guaiacum when it produces a loose state of the 
bowels. I must also observe," he adds, " that I have, in the course of 
administering tartrate of antimony for the treatment of rheumatic dis- 
orders, several times observed, that after it had produced rather profuse 
catharsis, the articular pains underwent remarkable abatement^ with 
reduction of the pulse to the natural standard ; and they finally disap- 
peared. Colchicum also very often purges smartly before it relieves the 
articular pains."§ It will be seen that free and repeated evacuation oi 
the bowels forms an important part of the plan of Dr Hope, which we 
shall allude to more particukrly hereafter. 

2d, The Stimtdant Sudorific Treatment. — One medicine of this class, 
Dover's powder, is regarded almost as a specific in rheumatism ; but 
whether it merits that character is rather doubtful. In the Edinburgh 
school it was largely employed, chiefly perhaps owing to the strong re- 
commendations of Professor Gregory, who regarded sweating as the 



• Practical Researches on Gout and Rheumatism, by James Johnson, p. 270. 

+ Cyclop, of Prac. Med., Art. Rheumatism. 

X Lectures by Cooke, p., 740. 

§ Craigie's Practice of Physic, voL ii.'p. 665, 



TREATMENT OF ACUTE RHEUMATISM. 77 

evacuation most to be Telied on after blood-letting. On this snbject Dr 
Hope obserres, — ** Dr Gregory, the great advocate of this plan, premised 
Tenesection and pniging till the pulse was lowered to 100, but * with these 
appliances and means to boot,' I have seen patients stewed and parboiled 
(if yon will excuse a culinary trope) for four, six, or eight weeks, and gain— 
what ! — a more attenuated frame, chronic pains, and a confirmed suscepti- 
bility of rheumatic attacks on the slightest variations of temperature* 
This plan is now, I think, almost universally abandoned — ^by those at 
least who keep pace with modem science."* The guaiacum, a remedy 
introduced by Dr Dawson, and still occasionally employed, though usually 
in chronic rheumatism, seems to owe any efiicacy it possesses to its 
sudorific powers. Dr Graves is an advocate for its employment in chionic 
cases where no symptoms of active local inflammation or general fever exist. 
The formula he prescribes is as follows^ — and he regards it as acting by 
increasing the secretion fix>m the skin, while at the same time it exercises 
a stimulant action on the nervous and capillary systems : — ^'^ Powdered 
bark, 3j> ; powdered guaiacum, 3j. ; cream of tartar, ^. ; flowers of sulphur, 
§8S. ; powdered ginger, 3j- : — ^to be made into an electuary with the common 
syrup used in hospitals.t The dose, a tea-spoonful three times a-day. 
This^ however, will be too much for some cases and two little for others. 
The object in every case should be to keep up a mild but steady action on 
the bowels, and to procure a full alvine evacuation at least once a- day. If 
the dose already mentioned does not answer this purpose, it must be in- 
creased ; if the bowels are too free, it must be diminished."^ An electuary 
nearly similar in composition was employed by Dr Law ; and Dr Mimk 
states that he succeeded in curing three hundred cases by means of sul- 
phur combined with carbonate of soda in the proportion of two drachms of 
the latter to an ounce of the former. We have no doubt that, restricted to 
the class of cases which Dr Graves has described, sudorifics vnll be foimd 
beneficial; but in the acute variety of the disease, where spontaneous 
sweating so often occurs, and proves any thing but salutary, this method 
of treatment does not seem to be indicated. ** The sudorific plan of 
treatment^" observes Dr Scudamore, ^not unfrequently disappoints our 
expectations, so as to aggravate rather than relieve the symptoms. Even 
when most successful, it is attended with the ill efiects of producing much 
debility, and increasing the sensibility of the surface, so that for a con- 
aderable time almost any degree of exposure is hazardous."§ And Dr 
Barlow, in his very excellent article before quoted, observes : " The cure 
of rheumatism by profuse perspiration has fidlen so much into disuse, that 
it can be hardly necessary to notice it." 

3d, Pure Stimulant Plan, — ^The exhibition of bark in the treatment of acute 
rheumatism was introduced by Morton, but as it was opposed by Cullen, 
it never obtained the confidence of the profession until after the publication of 
Dr Haygarth. The following is his account of his method of prescribing it : — 

* Medical Gazette, voL xix. 

-f- The above formula is similaT to that of the empirical remedy for rheumatism, 
termed the Chelsea Pensioner, the composition of which is as follows :.^Guaiac. 3i« ; 
powdered rhubarb, 3ii-; cream of tartar, Ji.; flowers of sulphur, Jii.; one nutm^ 
finely powdered ; — ^the whole to be made into an electuary with one pound of clarified 
honey. Two large spoonfuls to be taken night and morning. 

J Clinical Medicine, p. 663. 

§ Treatise, p. 542. 



78 TREATMENT OF ACUTE RHEUMATISM. 

*^ After the stomach and bowels have been sufficiently cleansed by anti- 
mony, I have for many years begun to order the powder of Peruvian 
bark in doses of gr, v. x. or xv. every two, three, or four hours ; and if this 
quantity had a salutary effect, it was gradually increased to gr. xx. xxx. 
or xl., with sedulous attention never to add more than what perfectly 
agrees : it has generally been taken in milk, mint water, or the decoction 
of bark." The results of this method of treatment, even on Br Haygarth's 
own showing, do not appear to have been very encouraging, as we find that 
he lost twelve cases out of a hundred and seventy ; and accordingly we are 
not surprised that it fell into desuetude. Of late, however, an attempt has 
been made to revive its employment, more especially among the Parisian 
practitioners ; and we find a letter addressed by M. Briquet to the Academy 
of Medicine of Paris, stating that lai^e doses of quinine were as successful 
in the treatment of rheumatism as of ague. The researches of M. 
Monneret bear upon this point, and we shall accordingly present an 
abstract of them, as they appear to be at once the most recent and the 
most accurate. In this valuable contribution, not only the effects pro- 
duced by the medicine on the disease are recorded, but its influence on the 
fleveral functions of the body ; we shall, however, restrict ourselves to the 
former. The sulphate of quinine was given to 22 IndividuaLs (17 males, 5 
females) ; 13 suffered from recent acute rheumatism, with fever, in several 
joints ; 3 had rheumatism in several joints without fever ; 3 rheumatism 
accompanied with fever in one joint ; in 1 the rheumatism was at once 
articular and muscular ; in the remuning 2, muscular and accompanied 
with neuralgic pains. The quinine was given in solution, with an excess 
of acid, and therefore in the state of bisulphate. The medicine was in 
every case persisted in for at least 10 days, sometimes for 14. One patient in 
8 days took 29 grammes* of the salt, and after a cessation of some days, 
during which he had been free from pain, he took, on account of the 
return of the pain, in all 47 grammes ; a second took 67 grammes in 12 
days ; a third 50 in 11. The smallest does was 2 grammes, the largest was 
6. Of the 22 patients, 7 only were cured ; and among these, one was affected 
with muscular and neuralgic rheumatism ; a second had articular rheuma- 
tism of 15 days' standing, and was almost free from fever ; a third had 
slight rheumatism with moderate fever ; in a fourth the pains were of 8 days' 
standing, and the other local symptoms slight; so that, in fact, only 3 cases of 
acute articular rheumatism appeared to yield to the remedy. In 1 6 other 
cases, the pains were remarkably alleviated, usually on the second or third 
day, more rarely on the first. In two-thirds of the cases, the pains ceased 
so entirely that the cure was regarded as complete, the patient being able to 
move his limbs without suffering, but they returned again, even although 
the remedy was persisted in. The sulphate of quinine produced a curious 
effect on the nervous system, which showed itself in two ways,— either in a 
state of great excitement resembling that of intoxication, or a state of 
collapse similar to that of typhus fever ; and it was remarked, that the 
effect upon the articular pains seemed to correspond with the intensity of 
the nervous affection. These experiments seem to be very accurate, and 
certainly do not give much reason for confidence in tlie curative power of 
quinine. 

The late Dr Davis, the professor of Midwifery in the University of Lon- 
don, recommends bleeding followed by an emetic, and in five or six hours 

* The gramme equals Id round numbers \ drachm or 15.440 grains. 



TREATMENT OF ACUTE RHEUMATISM. 79 

an active purge ; after which he gives from a scruple to half a drachm of 
powdered yellow bark every three or four hours. Under this treatment 
the disease seldom exceeded a week,* 

4ih, Calomel and Opium Plan, — The efficacy of opium in the treat- 
ment of rheumatism has been long known. De Roches cured two cases 
by its use alone^f and since then it has been recommended by several suc- 
cessive authors. The practice, however, has met with much opposition. 
Among those who condemn it are found the high names of Sydenham^ 
Cullen, and Armstrong. Dr Corrigan is an advocate for its employment, 
and did not find it affect the cerebral functions. The mean quantity 
which he exhibited was ten to twelve grains, but sometimes double this 
dose was given. Professor Christison recommends frequent doses of Dover's 
powder, which may relieve either by its opiate or sudorific properties. 
Other narcotics have been given, especially the extract of aconite, or that of 
belladonna. The calomel and opium plan, however, was first introduced by 
Dr Robert Hamilton of Lyme Regisj;, who first bled his patient, and then 
gave calomel and opium at suitable intervals, until the disease ceased, or 
the specific effects of the medicine were produced. Of all the methods of 
treatment this is perhaps the one in which the greatest confidence is placed, 
and more recent improvements have consisted merely in modifications in 
the method of prescribing it. 

5^, Specific Remedies, — Under this head we class a few agents, regarding 
the particular efi^ect of which on the constitution we are not sure, and 
which we cannot therefore arrange under any of the foregoing heads. Isty 
Colchicum is a remedy which has been lai^ely employed in the treatment 
of rheumatism, and generally with the most lytneficial effects. It is highly 
recommended by Dr Barlow, an author of great experience in these a^ec- 
tions, and indeed, in combination with other remedies, is employed by almost 
every practitioner of acknowledged reputation. It was with not a little 
sorprise, then, that we observed that the author of the article Rheumatism 
in the '^ Library of Medicine," states that colchicum has long held and 
continues to hold an ill-deserved reputation as a remedy for acute rheu- 
matism, and this upon the authority of eleven cases. On the same amount 
of experience, the same author gives the authority of his name against the 
use of calomel and opium. We shall give M. Monneret's observations upon 
this drug, made with the tincture of the bulb of the colchicum. Most of the 
patients took from 4 to 16 grammes in the 24 hours, — ^the one in one or two 
doses, the other in four doses. M. M. always exceeded the usual dose. He 
never commenced with less than 4 grammes, and he remarked that while the 
doses could be very rapidly increased, the large ones could not be safely con- 
tinued long. Some patients took it for 9, 10, or 13 days, but with an interval 
of 2 or 8 days. 21 patients were treated by this medicine, and, in all these 
cases, it was continued until M. M. was convinced that it was producing no 
effect. M. M. does not consider it necessary to state minutely the peculiar- 
ities of the cases, *^ because in not a single one was the use of the tincture 
of colchicum followed by. an evident and durable cure." But when we 
come to examine further, we find that 8 patients, that is to say, more than 
a third, recovered while taking it, and that all that our author means to 
assert is, that it cured them by means of its . powerful purgative effect, and 
not by any latent specific virtue which it might possess. This opinion we 

• Lancet, 1841. t Medical and Surgical Journal, vol. i. p. 154, 
{ Medical Commentaries, 1783. 



80 TREATMENT OF ACUTE RHEUMATISM. 

have already shown to be held by many British practitioners, who, in order 
to ensore the pui^tive effect, exhibit the colchicum in combination with 
saline aperients. *^ The two best internal medicines," observes Dr filliotson, 
** are without doubt colchicum and mercury. Colchicum here, as in the case 
of the gout, generally does no good till it purges, and when it once purges 
the patient thoroughly, the disease usually gives way. It should be given 
in Uie same way as in gout, that is to say, with magnesia, that it may 
produce its efifect as speedily as possible. As soon as it purges it is right to 
desist ; and also as soon as its effect ceases. If you give a dose of hydro- 
cyanic acid with the colchicum, it sits better on the stomach ; you may 
exhibit one, two, or three minims."* 

Dr Hughes gave a pill of opium and antimony at night, and half a drachm 
of the colchicum wine, with a drachm of the sulphate of magnesia, three or 
four times a-day, until copious, liquid, yellow evacuations were produced, 
when, if the pain was abated, bark and soda were prescribed. Mr Wigan gives 
8 gndns of powdered colchicum root every hour, until vomiting, purging, or 
profuse perspiration occurs. The minimum quantity is 5 doses, the maxi- 
mum 14, the average 8 or 10. 

2. Nitre. — ^This remedy was introduced in 1764 by Dr Brocklesby. A 
full account of it was given in the 5th Number of the Scottish and North 
of England Gazette, in which the observations of M. Martin Solon were 
condensed. His observations were made on 38 patients : of these, 20 were 
cured &om the Sd to the 7th day ; 11 from the 9th to the 10th ; 2 &om 
the 11th to the 15th. In 27 of these cases the malady ceased gradually 
after the exhibition of the remedy ; in 6, other articulations were attacked. 
In 9 cases, where bleeding was also employed, the convalescence seemed to 
be rendered more tedious, and two of these patients had relapses. The 
usual dose was 80 grammes in the 24 hours, and in ten cases it was carried 
as high as 00. In 9 cases it produced nausea, vomiting, and purging, but 
this was removed by adding syrup of poppy to the lemonade in which it 
was usually given. Dr Brocklesby gave 18 drachms in the 24 hours ; Mr 
White, 12 drachms. Mr Home recommends the following mixture : — 
R. nitratis potassfe, 553. ; tart antimonii, gr. ii. ; spt. stheris nitrici, §i. ; 
aque fontis, §xii. : misce. A wine-glassful three times a-day .t 

M. Monneret tried nitre in 8 cases, in all of which the rheumatism was 
recent and intense. One of the patients suffered from meningitis, and an- 
other from pneumonia; the dose given was fi-om 8 to 30 grammes. M. 
Monneret could not observe any benefit result from its employment. He 
never gave more than 30 drachms. The articular pains, the fever, the 
state of the pulse, and the urine, were unaffected by its employment, nor 
did the latter exceed the quantity of fluid swallowed. In all these cases 
the remedy had to be changed in order to prevent serious resulta. 

3. Iodine. — Dr Cowan gave the hydriodate of potass in 52 cases, in 
average doses of five grains three times a-day. In no instance was either 
bleeding or leeching prescribed. The following is his opinion of its powers : 

** The action of iodine in rheumatism is, on the whole, satisfactory ; in 
many cases it may be regarded as heroic, while in others not a priori dis- 
tinguishable, almost negative. After examining the experience of different 
observers, we are inclined to suspect that we have often erred by the small- 
ness of the dose, and think it probable that the quantity should in some 



• Letters by Cooke, p. 740. t Lancet, Dec. 10, 1842. 



TREATMENT OF ACUTE RHEUMATISM. 81 

cases be increased to the point of tolerance, the rheumatic element^ so to 
speak, varying in amount and intensity in different individuals." 

" In the I^cet for Nov. 16, 1839, Mr Henry Rees says, * In all cases 
of acute rheumatism the diet should be strictly regulated ; avoid rigidly 
beer, wine, spirits, and animal food. Milk, beef- tea, butter, eggs, fish, &c., 
are all pernicious. His theory is, that the disease depends on an excess of 
nitrogen. In very urgent cases bleeding and mercury may be necessary ; 
but he regards the hydriodate of potass as certain an antidote to the rheu- 
matic diathesis as mercury is to that of syphilis. Its combination with 
liquor potasse acts, he says, like a charm in rheumatic iritis." 

"In a very obstinate case, characterized by severe pains, relieved by 
heat, and unaccompanied by much swelling, occurring in the practice of 
Mr John Brady of London, the following means proved very successful : — 
Compound extract of sarsaparilla, six drachma ; iodine, half a grain ; 
hydriodate of potash, half a drachm ; boiling water, six ounces : mix. A 
fourth part three times a- day, with one of the subjoined pills. Hydro- 
chlorate of morphia, one grain ; disulphate of quinine, nine grains ; blue 
pill, ten grains ; rhubarb j)ill, twelve grains. Divide into twelve pills." 

Dr Graves recommends hydriodate of potass in lumbago. 

" I first became acquainted with the remarkable efficacy of this medicine 
in lumbago and sciatica, under the following circumstances. In the mem- 
orably wet month of July 1839, 1 Was called out of bed at midnight to visit 
a lady in the country, and the vehicle sent to convey me was a hack, covered 
car. The cushions wfere Very damp, Aad I had not proceeded half a mile 
before I was attacked with lumbago so severe that I could scarcely walk 
when I arrived at my patient'^ residence. Next morning I was better, 
having perspired much during the night ; but still the pain was troublesome^ 
and as the season continued unusually cold and wet (indeed it scarcely ever 
stopped raining from the 8th of July 1839 to the 19th of February 1840), 
and as my duties exposed mc much to the weather, and prevented me from 
giving myself the necessary rest, my lumbago continued to increase again, 
and in about a month, the gluteal and sciatic nerVes of the left side became 
engaged ; I noted particulatlyj thtit the pain spread very gradually down- 
wards from the lumbar region, so that it took a week or ten days to arrive 
at the ham, and a still longer time at the ankle. I was then quite lame of 
the left leg, suffered much from {>ain in bed, and had become so helpless, 
that I had to get my servant to draw on my stockings. During all this time 
my general health was perfect, appetite good, digestion regular, and no 
deviation of the urine from the natural appearance. I mention this because 
several of my medical friends advised me to take antibilious Aperients, an 
advice founded on Abemethy's doctrine, that many local affections proceed 
from stomach derangement. I was at last forced to try sdmethltig for my 
relief, and had myself cupped, and tried the w^arm douche and Dover's 
powder, but without any good effects. I began now to fear that I should 
be forced to give up all prdfessioiial business, and confine myself to the 
house for many weeks, in order to go through a mercurial course^ combined 
with proper topical applications, when happening to meet Mr Ferguson of 
Kildare Street, he reconmiended me to try hydriodate of potash, of which 
he was good enough to send me a drachm dissolved in a pint of decoction of 
sarsaparilla. I took a quarter of this daily, and may literally apply here the 
common phrase, that I felt each dose do me good ; in truth, the benefit I 
derived was perceptible hourly, and was so rapid, that in four days all traces 

of the lumbago were gone, and my lameness had quite ceased. I did not 



82 TBEATMENT OF ACUTE RHEUMATISM. 

take more than one bottle, t. e. one drachm of the hydriodate ; but the good 
effect continued after I had ceased taking it, and in less than a week I was 
perfectly well. Subsequent experience enables me to recommend this 
medicine strongly in sub-acute and chronic lumbago and sciatica.* 

" It is right to observe, that the remedy had in my own person to work 
against various disadvantages, for I neither relaxed froni my labours nor 
refrained from eating and drinking as usual. This is only another exaxx^le 
of the many I have met, which prove how injudicious it often is to seek 
the cure of local inflammations by means of lowering the whole system."t 

We shall lastly present our readers with a summary of the method of 
treatment adopted by several practitioners^ and leave them to judge for 
themselves as to the plans proposed. 

Mr Baynton of Bristol orders all mufflings off his patients, and ad- 
mits a free circulation of cool air through the chamber by open windows. 
Absolute quiescence is enjoined, the most rigid abstinence is to be observed, 
and no medicine is given except gentle laxatives ; the shower bath is to be 
used during convalescence. 

" The late Dr Hope, after six years' experience upon 200 cases^ gives de- 
cided preference to the following plan : — After one or even two fiill bleed- 
ings in the robust, he gave seven to ten grains of calomel, with one or two 
of opium at night, a draught with fifteen to twenty minims of colchicum 
wine, and five grains of Dover's powder in saline mixture, three times a-day. 
It was seldom necessary to repeat the calomel moi'^.than from two to four 
times, ailer which he continued the opium at night, with the colchicum 
draught and a senna laxative every morning. The patient was almost always 
well in a week, and able to commence his work in seven to ten days after the 
pains had ceased. Ftyalism was avoided unless the heart was involved. 

**" In chronic cases he gave five grains of calomel, and one of opium, at 
night, for five or six times, with the senna and colchicum draught as before. 
Local depletion with some form of counter-irritation wei*e usually employed. 

** Dr Macleod advises bleeding, abstracting from twelve to thirty ounces 
during the first week, giving three to five grains of calomel at night, and a 
senna purge in the morning. Opium to the extent of two grains in the 
twenty-four hours is often useful, and the guaiacum is recommended as 
the best after-treatment. In lumbago Dr M. thinks well of a brisk calomel 
pui^e once or twice a- week as above, and considers half a drachm to two 
drachms of the compound tincture of guaiacum three times a-day, with a 
grain of opium at night, the best plan." 

*^ Against rheumatic headach Dr Johnson has found no treatment so 
successful as the following : — Eight grains of Dover's powder and two of 
calomel at bed-time, on alternate nights, for two or three times, followed by 
a third part of the following mixture the next morning, to be repeated in 

• " My friend Dr Osbrey, in an exceedingly useful paper on the * Usea of some 
of the Combinations of Iodine,* published in the twenty-first volume of the Dublin 
Medical Journal, makes the following remarks, the importance of which I fully 
admit : * The readers of this journal are aware that Dr Graves has strongly recom- 
mended the use of iodide of potassium in lumbago, for which I have found it an 
excellent remedy. There is one form, however, of rheumatism of the muscles of the 
back and loins, in which it should be used with caution ; it is that which is attended 
with dyspeptic symptoms, such as flatulency, diarrhcsa, and irritability of the 
stomach ; these symptoms, in my opinion, should be first relieved before having 
recourse to iodine. In sciatica I have also found that remedy useful.* " 

t Clinical Medicine, p. 864. 



GROWTH OF NEW BONE. 83 

two hours, if necessary : — Infusion of rhubarb, three ounces ; tartrate of 
soda, three drachms ; powder of rhubarb, half a drachm ; tincture of senna, 
half an ounce ; wme of colchicum, a drachm and a half : mix. 

" The same observer remarks (Medico-Chirurgical Review, April 1838), 
that many of the most stubborn cases will yield to a course of blue or 
Plummer's pill, taken at bed-time, and foUowed by a warm saline and 
oolchicum draught in the morning. Flannel clothing, and an occasional 
warm bath, are valuable adjuvants." 

" In the acute stage Dr Graves principally relies on bleeding, with large 
doses of tartar emetic and nitre ; and in less urgent cases, particularly if 
complicated with bronchitis, he has derived much benefit from the follow- 
ing mixture :~^Almond emulsion, eight ounces ; vinegar of colchicum, half 
an ounce ; acetate of morphia, one grain ; nitrate of potash, half a drachm : 
mix. Half an ounce every hour or every two hours." 



MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN. 

Qrwoth of New Bone on the Internal Surface of the Cranium in Pregnant 

Females. 
M. Ddcrest has published a memoir on this subject, founded upon 231 
observations, which- he has made in women who haver died in or shortly 
after childbed. He commences by detailing 10 cases in which the osteo- 
phyte may be traced through its various pliases. In its earliest stage 
nothing attracts attention but red spots, which occupy one, two, or more of 
the depressions on the cranium corresponding to the cerebral convolutions. 
When these patches are scraped they are found to consist of layers of a 
reddish matter on which there is as yet no hard substance. The patches, at 
first isolated, nnite, enlarge, and constitute on either side of the cranium 
(for they are developed symmetrically) extensive layers, which ultimately 
join in the median line. A few patches have been found at the base of the 
cfanium ; but the frontal region is that on which they are most commonly 
observed. As these patches increase in extent, they acquire greater firmness, 
and approach more and more to bony hardness. Nevertheless, their consis- 
tence is not always in proportion to their extent ; for they are sometimes 
found to cover the whole inner surface of the skullcap, and yet to be cut 
as easily as cartilage, while at other times, when in much smaller patches, 
they are with difficulty marked by the edge of the scalpel. When the 
osteophyte is in its rudimentary state, the only trace of tissue which can 
be perceived is a tortuous vascular network ; when somewhat further ad- 
vanced, it is composed of two distinct layers, the one of compact tissue in 
connexion with the dura mater, and the other of spongy texture applied on 
the inner table of the skullcap. After describing the new product, the 
author passes to an examination of the adjoining structures — the dura mater 
and the cranial bones ; in the foimer he has never found any variation from 
the natural condition, but in the latter he has constantly observed increased 
vascularity in the parts adjoining the new growth. The osteophyte does 
not appear to give rise to any inconvenience, nor to any symptoms by which 
we could pronounce on presence during life. Out of 231 cases of women 
who had died in childbed, M. Ducrest has observed the " exostose epiphy- 
wire" in 91 instances ; the number of pregnancies does not appear to pre- 
dispose to the development of this new product ; and M. D. sums up his 
observations with the four following conclusions : — 1. There is found in the 
cranium of women who have died in childbed a production at first cartila- 



84 GROWTH OF NEW BONE. 

ginous, but which ultimately becomes osseous ; 2. The craniam and dura 
mater in connexion with the osteophyte present no special lesion ; 3. It is 
most commonly met wuth in young females ; 4. Its presence does not give 
rise to any peculiar symptoms. — Memoires de PAcadtmie Medicale d'Observa- 
tion, 1844, tome ii. p. 381. 

Several of the statements advanced as facts by M. Ducrest are totally at 
variance with the observations both of Professor Rokitanski and our own. 
We imagine M. D. to be perfectly ignorant of the extreme attention paid 
to this subject for many years past by Prof. R. ; for M. D. tells us that it 
is " une chose fort peu connue" and his account is not to be compared either 
for accuracy or completeness with that of Rokitanski published in the 
Oesterr Med, Jahrl for 1838— six years ago. We have had opportunities of 
assisting at several of Prof. R.'s investigations, and it has always appeared 
to us that the new bone grows on the elevations of the inner table of the 
cranium, not, as stated by M. Ducrest, on the depressions : we do not, how- 
ever, agree with Rokitanski in thinking that its growth is confined to the 
elevations because the brain exerts greater pressure on the depressions than 
on the elevations, for we should suppose this to be equal on all points 
within the cranium. It is most frequently, also, very thick and fully 
developed along the course of the large vessels, for example, along the track 
of the arteria meningea media and the longitudinal sinus. Professor 
Rokitanski observed the new product in more than the half of 1500 cases 
of puerperal females, whose bodies he examined in the space of ten years ; 
and as the greater number, if not all of them, had died of some variety of 
the affection termed " puerperal fever," he concluded that it had some con- 
nexion with that disease ; but later investigation — ^in pregnant women, for 
example, who had died of the most rapid form of Asiatic cholera, and in 
whom he found the osteophyte — caused him to avow the incorrectness of 
his first supposition. We have ourselves seen it where the females have 
died from hemorrhage, convulsions, rupture of the uterus, and phthisis ; it 
has been seen previous to the sixth month of pregnancy, and so late as three 
months after delivery ; and does not appear to be developed in cases of extra- 
uterine pregnancy, moles, or polypi. In the opinion of Rokitanski, it is 
in some way connected with the cessation of the menstrual discharge. His 
theory is founded on the statement of Retzius, that the menstrual dischax^ge 
contains free phosphoric and lactic acids ; and he thinks that the phosphoric 
acid thus retained in the system may be periodically employed in the pro- 
duction of new bone, and that therefore the osteophyte ought not to be 
found in those females who have menstruated or suffered much from 
acidity of the primse vise during pregnancy, as, in either of these cases, the 
acid is eliminated from the system. This is an hypothesis, however, which 
will require to be tested by the observation of years. Prof. R. endeavours 
to support this theory by the fact, that once in a chlorotic virgin he ob- 
served hyperostosis of the cranium ; in this case there was also deposit of 
phosphate of lime on the mitral valve. In general this hyperostosis is pro- 
ductive of no bad consequence ; but a very singular case— one Highly inter- 
esting in a physiological point of view — is recorded, whei'e the bony growth 
encroached upon several of the foramina at the base of the cranium through 
which the nerves pass out, and induced a series of remarkable nervous 
symptoms, ending in the death of the patient.* The exostose epiphyaaire 
has been found on all the bones of the cranium and face, but never on those 
of the trunk, pelvis, or extremities. 

* Hufeland's Journal der Pract Halkunde^ Juni 1840, 8. 61. 



PREGNANCY WITH IMPERFORATE AND BILOCULAR UTERUS. 85 

Pregnancy with Imperforate and Bilocular Uterus. 

Dr Lumpe of Vienna was called to attend a female, st. 30, in her first 
confinement. An examination per vaginam detected that that canal ap- 
peared to he partially closed up, at the distance of two inches from the 
external part^ hy a structure composed of interlaced fibres of different 
thickness ; ahout an inch and a half above this, on the posterior wall, 
the vagma seemed to end 'm& cul de sac. No vaginal portion of a uterus 
could be discovered. The urethra was so wide that the finger could be 
easily introduced into it, and the foetal head felt pressing into the pelvis. 
When the first pains occurred, the portion of the posterior vagin^ wall 
beyond the septum was perceived to widen, so that the point of the finger 
could be farther advanced, and an incision was just al^out to be made into 
this part, when a violent uterine contraction supervened, two or three 
ounces of blood were effused, and soon thereafter the liquor anmii escaped. 
On examination, there was discovered a rough transverse opening, high and 
posterior, which rapidly widened, and through which a living child was 
soon after born. A few days thereafter the patient was seized with metro- 
peritonitis, and died in four days. On dissection there was found violent 
peritonitis with much exudation ; the cavity of the uterus was divided 
vertically by a partition wall, down to the internal orifice of the cervix, 
into two portions ; the left had been pregnant, the right division was 
widened, increased in volume, vascular, and coated with a fine membranous 
exudation (the decidua 1) The cervix and orifice were natural. — Oesterr 
Mediz Wochenschrift^ No. 37, 1843. 

The above detail would lead us to suppose that a rupture took place 
somewhere, were it not that the os and cervix uteri are said to have 
been natural : the case is certainly not clearly recorded. The practice of 
making an os uteri by incision when one does not naturally exist must 
always be attended with much danger, as there is no possibility of prevent- 
ing the incision being prolonged by laceration. The practice has however 
been in a few cases attended with a successful result. It is rarely indeed 
necessary ; for although, previous to the supervention of labour, experienced 
accoucheurs have been unable to discover any trace of an os uteri, the 
parturient efforts do not last long before the aperture appears and dilates 
with tolerable ease. Another point of interest in the preceding case is 
the circumstance that a decidua existed in the unoccupied half of tlie 
uterus ; this is an additional proof that the decidua is not an adventitious 
membrane caused only by local irritation, as some would have us believe, 
but a veritable hypertrophy of the mucous lining of the uterus. We 
know that during pregnancy the uterus as a whole grows, that its nerves 
and vessels individually enlarge, and why not its mucou9 membrane 1 



FORENSIC MEDICINE AND MEDICAL POLICE. 

Term of Pregnancy exceeded by Four Weeks. 

A PREGNANT womau, who had already borne three children, was attended 
by Dr Hayn of Konigsberg for " gastro-nervous fever." The affection was 
so severe that premature labour was threatened. Dr H. made an examina- 
tion per vaginamy and felt satisfied, as well from this as from the woman's 
account, and her other symptoms, that the natural term of her utero-gesta- 
tion would expire about the 23d of May 1841. The patient recovered from 



86 TERM OF PREGNANCY EXCEEDED. 

her fever, and at the aboye-mentioned date was seized with weak Ubour 
pamsy copious mucous secretion from the vagina, and remarkable sinking 
of the uterus into the pelvis. After three days the pains wore away ; and 
four weeks thereafter the woman was with difficulty delivered of an unusu> 
ally large child. — Ciuper's Wochenschrift^ No. 47, 1843. — The question of 
protracted gestation has given rise to considerable discussion in courts of 
law, and we have thought fit to extract the foregoing case ; for, in the words 
of Mr Taylor, in his excellent Manual of Medical Jurisprudence, ^ it is only 
by the accumulation of well-ascertained facts, from all authentic sources, 
that medical knowledge can be made available to the purposes of law.'* 
We should suppose that no one at the present day doubts of the occasional 
protraction of gestation for two, three, or even four weeks. It would be 
much better that, in reckoning the duration of pregnancy, it should be 
counted by months of 28 days only ; for such a month is a determinate definite 
period, not liable like the calendar month to vary from 28 to 31 days. Of 
course the objection urged to all such cases as the above is, that " there 
has been some error in the calculation.'* The remarks of the author whom 
we have already quoted on this subject are so excellent that we shall extract 
them for the benefit of our readers : — <' It is impossible to admit that these 
cases depend on some mistake being made in the calculation of the period, 
since this calculation was founded upon the same principles as those adopted 
in cases of ordinary pregnancy. Hence, if there were a mistake in the one, 
there would be in the other, — if an error in the exception, there would be 
m the rule. Either pregnancy is wrongly calculated at the thirty-eighth 
and fortieth week, or it is rightly calculated to extend occasionally to the 
forty-fourth week," 



Toxicohgicdl Effects of the Sulphate of Quinine^ hy M, Monneret, 

The author states that, when the sulphate of quinine has been given for 
a long period and in large doses, it produces certain poisonous efi^ects 
characterized by three distinct orders of phenomena, — 1st, nervous derange- 
ment ; 2dly, gastro-intestinal irritation ; and, 3dly, a state which he terms 
** typhique" on account of its resemblance to typhoid fever. 1st, The nervous 
derangements manifest themselves in half or a quarter of an hour after the 
exhibition of the dose ; there is noise in the ears, almost invariably vertigo, 
and sometimes stupor, but no headach, how severe soever the other symp- 
toms may be ; vision becomes confused, and objects are perceived as if 
through a mist. Amaurosis was met with in four instances ; in one of these 
the patient had taken 15 grammes * of the sulphate ; a female who had 
taken the same quantity in three days, lost her sight entirely for five days. 
** Vivreese quinique" chinic intoTUcation, shows itself of two kinds; either as 
a state of great excitement, or of collapse, the latter being the most common. 
In the former variety the patients are agitated, attempt to get out of bed, 
speak in an agitated, tremulous, indistinct voice, and, if they have been 
previously rheumatic, declare that their pain has entirely left them ; in the 
latter form there is exhaustion, stupor, feebleness, a certain slowness of in- 
tellect and memory, and disinclination for food ; at the same time the eye is 
** teme," " abattu," and glassy, the eyelids half open, the countenance much 
disturbed, and the noise in the ears and vertigo intend. — 2dly, Qastro intest- 
inal symptoms. After the nervous symptoms have manifested themselves, 

• The gramme is equal to 15*434 English ttoj grains ; say in round numbers 
ltS\ grains. 



TOXICOLOGICAL EFFECTS OF THE SULPHATE OF QUININE. 87 

ihere is a disagreeable, sometimes a painful sensation opposite the inferior 
extremity of the sternum, occasionally also symptoms of irritation of the 
oesophagus and cardia. Of twenty-two individuals affected with rheu^ 
siatism to whom the quinine was administered, six suffered from gastro* 
intestinal inflammation characterized by the following signs: — Tonguo 
red, dry, and rough ; this organ as well as the lining membrane of the 
mouth was spotted with patches of diphtherite, which in one case ex- 
tended into the pharynx ; extreme thirst ; frequent bilious vomiting ; 
edic pains and tension through the whole abdomen ; constipation followed 
by diarrhoea; in one case the numerous stools c(»isisted almost entirely 
of pure blood mixed with &lse membrane ; in another the inflammation 
was moderate in the stomach and small intestines, but severe in the large ; 
there was violent pain along the course of the colon, frequent serous eva« 
cuations, with tenesmus and heat at the anus. The gastro-enteritis lasted 
for a considerable period, and was liable to return. It was very severe in 
three cases, in one of which the fli'st dose of quinine sufficed to cause severe 
intermitting abdominal pain, not increased on pressure, but which was 
quickly followed by the symptoms above described ; in the other two 
cases the symptoms were not developed until the quinine had been taken 
in large doses for ten or eleven days. — 3dly, The typhoid symptoms are de- 
veloped shortly after the others ; the countenance expresses stupor and dul* 
ness. In two cases only the typhoid appeared unaccompanied by any other 
phenomena. In six cases it supervened on gastro-enteritis ; in Ave of these 
cases it was accompanied with great prostration and repeated epistaxis ; in 
the sixth — ^that in which the irritation predominated especially in the laige 
intestine — the typhoid symptoms were slight ; but in all the intellect was 
weakened and slow ; in one patient there was hemorrhage from the urinary 
passages, and small ecchymosis on the abdomen ; in another menstruation 
appeared copiously twelve days before its proper period. — 4thly, Effects 
en other functions* One patient suffered &om extreme itching of the 
skin, without any appreciable eruption ; in a second, there was disagree- 
able pricking in the soles of the feet ; in a third, an eruption like rubeola, 
bat without any of the other phenomena of that disease ; in a fourth, true 
scarlatina, with its local characters only ; in a fifth, papulae on the abdo- 
men, which quickly disappeared ; in a sixth, papulae mixed with petechiae. 
The urinaiy secretion was not increased, but sulphate of quinine could be 
detected in it twenty minutes after the exhibition of the salt, and could still 
be discovered in that secretion long after the poisonous symptoms had dis- 
appeared. — Journal de MedecinCf Nos.for January and February 1844. — ^AU 
of the patients alluded to in the foregoing detail were under treatment for 
rheumatism ; the quinine was generally given in solution with a slight ex- 
cess of add, in the dose of two grammes a-day, gradually increased to six. 
One patient took twenty-nine grammes in eight days, a second fifty-seven 
in. twelve days, and a third fifty in eleven days. 



Part IV.— MEDICAL MEMORANDA. 



THE LATE DR ANDREW MOIR. 

It is with deep regret that we announce the death, on the 6th inst., of the 
late Dr Andrew Moib, Lecturer on Anatomy in King's College Medical 



88 THE LATE DR ANDREW MOIR. 

School. Cut ofiF at the early age of 38 years, from contagious fever, caught 
in the discharge of his profession, his death has deprived Aberdeen of a 
townsman of whom she had reason to be proud, and her medical school of 
one of its most efficient teachers. What adds to the melancholy nature of 
the event is, that Dr Moir has left an aged mother, a widow, and three very 
young children (the last of whom was bom two days after his decease), 
totally unprovided for, without relatives, and destitute even of temporary 
supplies. 

Unknown to many of his fellow-citizens, because occupying no prominent 
place in the eye of the public, Dr Moir nevertheless possessed talents of a 
very high order ; and, what is more, he rendered services to the community, 
and made sacrifices in the performance of them, which entitle his memory 
to lasting honour, and his bereaved family to the warm sympathy of the 
benevolent. 

We regret that we are precluded, by want of space, from giving an outline 
of his eventful history. Suffice it to say, that, within a short time, Mr 
Moir completely established his reputation as a teacher, secured himself 
in the esteem and patronage of the medical students, whom he drew in great 
numbers annually to his class, and commanded the confidence of his seniors 
in the profession. For eleven years, during which he was a private lecturer, 
he taught anatomy under very disadvantageous circumstances, encountering 
difficulties such as few but himself could have borne up under. Twice his 
property was burnt and destroyed by the populace ; and the circumstances 
attending the last popular outbreak, in 1882, the numbers and exasperation 
of the people, the personal injuries he received, and the narrow escape he 
made with his life, the calling out of the military, and the sensation it ex- 
cited all over the town, will be fresh in the memory of many of our readers. 
It would require the imagination of Dickens to do justice to the scene which 
was then exhibited ; and, in truth, it would form a fine subject for his pen. 
In 1839, the University School, then under the joint patronage of King's 
and Marischal Colleges, was broken up, and each college set up a medical 
school of its own. Mr Moir was chosen by the professors of King's College 
their lecturer on anatomy ; and such was the sense they entertained of 
his distinguished merits as a teacher, that they unanimously conferred upon 
him, in 1840, the honorary degree of M. D. 

The situation of Dr Moir's bereaved and destitiite family has a strong 
claim on the sympathy of a generous public — ^a claim which, we are sure, 
will not be disregarded. Indeed, we have evidence that active exertions are 
making among his late professional friends, in Order to secure some provision 
for them ; and that a general feeling, which we al-e anxious to foster, prevails 
among the whole community to come forward in their behalf. Mr Robert 
Dyce, advocate^ has, we are glad to learn, kindly consented to act as trea- 
surer ; and he, or any of the medical gentlemen in town, will be happy to 
receive the contributions of the benevolent. 

It speaks strongly for the estimation in which the late Dr Moir was held, 
that his remains were, on Monday last, followed to the grave, from the 
Medical Society's hall, by the whole faculty, the medical students, the 
medical professors and lecturers, both of Kkig's and Marischal Colleges, 
and a lai^e body of private friends. — Aberdeen Journal^ February 14, 1844. 



Printed bjr OUvfer & Boyd, Tweeddale Court, High Street, Edinburgh. 



THE 

NORTHERN 

JOURNAL OF MEDICINE. 



No. II.— JUNE 1844. 



Part I.— ORiaiNAL ARTICLES. 



Condyloma, a Primary Form of Venereal Disease identical 
with Sibhens. By David Skae, M. D., F. R. C. S., Lecturer on 
Anatomy, Surgeon to the Lock Hospital, Eye Dispensary, &c. 

The flat and whitish elevations of the skin occurring on the verge 
of the anus, on the perinasum, labia, or scrotum, and occasion- 
ally on the thighs, or even in the axillae, and known under the 
names of condylomata, tubercules muqueuses, &c., are in this 
country generally ascribed to one of two causes. By some of our 
most distinguished writers they are ascribed to inattention to 
cleanliness in persons labouring under chronic discharges from 
the genital organs. " These soft excrescences," says Dr Adams, 
" arise sometimes in consequence of a discharge from the rectum 
stimulating the neighbouring parts to ulceration. If such ulcers 
are prevented from healing by the discharge continuing, or by 
the friction of the parts, they must either ulcerate deeper and 
wider, or the cuticle will sefld out processes to defend them. 
These, on accoimt of the pressure they receive, grow in various 
shapes, from which they have acquired their names. 

" They will arise from a venereal origin in two ways. If a 
secondary ulcer is seated in these parts, that ulcer, having no 
power of healing itself, will take the character above described 
from the nature of the parts. Sometimes, also, the matter of 
gonorrhoea, by falling from the vagina along the perinaBum, 
will produce ulceration, and the same consequences follow."* 

« Admi on Hwbid Vovww, London^ 1807, ^ 179. 

M 



90 CONDYLOMA OR SIBBENS, 

By others these condylomata are believed to be identical with 
the scaly eruption which follows the true syphihtic sore, modified 
in its appearance by the situation where it occurs. " When the 
eruption," says Mr Carmichael,* speaking of the scaly syphi- 
litic eruption, '* affects a skin which is opposed by another skin, 
as between the nates, or between the scrotum and thigh, or 
under the arms, or between the thighs, it is not scaly ; but the 
skin becomes elevated into a moist, soft, flat, or somewhat con- 
vex surface, which discharges a whitish matter. These are the 
appearances which, I believe, in authors are termed condylomata, 
fici, cristaD, mariscaB, &c. — denominations applied according to 
their figure, or perhaps the fancy of the practitioner." 

The opinion last cited is the one generally adopted by most of 
our systematic writers on surgery regarding condylomata. By 
M. Ricord and other continental writers they are arranged with 
the secondary symptoms of syphilis. With pretty extensive 
opportunities of observation in the Lock Hospital of this city, I 
myself entertained the opinion for some years, that condyloma 
was a consequence of filth and protracted gonorrhoeal or leucor- 
rhoeal discharges ; nor is it surprising, for in a great number of 
the cases — and they always constitute a large proportion of those 
under treatment in the hospital — these condylomatous excres- 
cences are seen in females who either have had, or are at the 
time labouriflg under, chronic discharges from the uterus or 
vagina. 

In 1835, the late Dr Wallace of Dublin, in a series of clinical 
lectures published In the Lancet, announced some new views 
regarding the nature of these excrescences, or, to speak more 
correctly, of this peculiar eruption. He was the first to point 
out that it was almost invariably associated with a certain group 
of symptoms of a peculiar and definite character. Of this group 
the most remarkable pointed out by him was a peculiar morbid 
state of the mucous surface of the lips, cheeks, palatine arches, 
or tonsils. This morbid state consisted in peculiar white ele- 
vated patches, having the appearance of parts touched with 
nitrate of silver, or coated with milk ; these patches are more 
or less elevated, irregular in form, and presenting occasionally 
superficial ulcerations on their surface. 

Dr Wallace further pointed out that these spots were asso- 
ciated with, or rather preceded in general by, an exanthematous 

* Carmichael on the Venereal Disease, &c., Dublin, 18U, p. 42. 



A PRIMARY FORM OF VENBREAL DISEASE. 91 

eruption of a mottled appearance, and of a red or brownish 
colour, sometimes preceded hj vesication or scaliness, but never 
bj pustules ; sometimes elevated and approaching in appearance, 
in Yarious parts of the skin, to the mucous tubercles or condylo- 
mata commonly observed on the genital organs, and producing 
in the folds of the skin (as between the fingers, &c.) those linear 
ulcerations called rhagades; under the nails, onyxis ; in the head, 
&c., falling of the hair. 

From these and other facts, he inferred that condylomata, and 
the peculiar patches on the mucous membrane of the mouth and 
fEtuces, were parts of the same exanthema, modified in appear- 
ance by the tissue where they appeared, and constituting a group 
of " constitutional," to use his own words, " or secondary vene- 
real symptoms, of which condylomata, rhagades, onyxis, falling of 
the hair, and a pecuUar state of disease of the mucous membrane 
of the mouth, are the most remarkable." To this group of 
symptoms he gave the name of '' exanthematic primary sy- 
philis." 

He further asserted, that it could be propagated by inocu- 
lation and by simple contagion, and that it did not differ in its 
origin from syphilis, but resulted from a peculiar modification of 
the syphilitic virus from its having passed through the system. 
" The exanthematous group of venereal eruptions," he says, 
" are produced by secondary matter, or by matter originally 
derived from the common pustular primary sore, and snhsequently 
modified by passing through the system."* 

After the extensive series of experiments performed by M. 
Ricord with the matter of secondary syphilitic sores and erup- 
tions, and the verification of his results in the hands of others, 
it can scarcely b^ doubted that it is impossible to produce a 
venereal sore of any kind, much less the peculiar group of symp- 
toms described by Dr Wallace, by inoculation with matter so 
modified. I do not say that it is impossible to reproduce condy- 
loma by inoculation from the matter of a condyloma^ but that 
there is no evidence that condyloma can be produced by inocu- 
lation with the matter derived from an undoubted secondary 
syphilitic ulcer or eruption. 

This conclusion, while it appears to overturn the ingenious 
theory of Dr Wallace, leads, if the facts stated by him regard- 
ing the symptoms of this affection are correct, to the adoption of 

« Lsneet, 1835.6, vol. il. p. 198, 



92 CONDYLOMA OR SIBBENS, 

another view of the subject, now becoming prevalent in some 
parts of the Continent, namely, that condyloma is a primary form 
of venereal disease, distinct from either gonorrhoea or syphilis, 
but equally definite and specific in its character with the latter 
affection. This opinion is now entertained in some of the prin- 
cipal hospitals of Eussia, Austria, and Germany, where the 
affeciion is described as a primary disease, nnder the name of 
fdgwarzen. My attention was directed to the investigation of 
this subject only a few months ago by Dr Koch, one of the physi- 
cians of the Hospital of St Paul and St Peter at Petersburg ; and 
I have since that time carefully examined the patients present- 
ing themselves at the Lock Hospital labouring under this dis- 
ease, with a special reference to the question of its primary and 
specific character, and have also, in every instance, endeavoured 
to reproduce the disease by inoculation. The following is the 
result erf my observations and experiments, extending over a 
period of six months, viz. from 2d November 1843 to 2d May 
1844. 

The total number of patients admitted into the hospital during 
that period was 121, and the average number in the hospital 
was about 28, the whole of them being females. Of that num- 
ber 36 were affected with condyloma, being about one in 3J. 

One of the symptoms which struck me as most remarkable, 
and present nearly in all the cases, was a peculiar hoarseness or 
huskiness of the voice. This symptom was much more marked in 
some than in others, but could be distinguished, I think, in all ; 
even in those in whom no morbid change was visible in the 
mouth, fauces, or pharynx. 

The appearances presented on the genital organs and parts in 
the immediate neighbourhood, were moist, indurated, and some- 
what elevated patches, of a whitish and occasionally yellowish 
white colour. Most of these patches were irregular in form, but 
a considerable number of them, especially of those on the labia 
and thighs, were rounded and prominent. They were situated 
most frequently along the opposite margins of the labia majora, 
on the perinaBum, and verge of the anus ; less frequently on the 
outer surfaces of the labia and adjacent surface of the thighs, 
and on opposite and corresponding surfaces of the thighs, two or 
three inches below the labia. Many of them were the seats of 
superficial ulceration, or more frequently of vesication, the sur- 
face of the condyloma discharging a thin muco-purulent secre- 
tion. Those which were situated on the opposite sides of the 



A PRIMARY FORM OF VE^ERBAL DISEASE. 93 

Rat^ were less elerated, and pf esented a tendency to ulcerate ir 
fissures as they approached the yerge of the anus. 

In two instances, three or four considerable condylomatous 
patches, white and elevated, although flat, were seen extending 
oyer the inner surface of the yagina as high as the ceryix uteri. 

In nearly all the patients, the mouth or fauces presented the 
appearances described by Dr Wallace as characteristic of this 
affection. These consisted in white and slightly eleyated patches 
on the inner surface of the lips or angles of the mouth or cheeks ; 
more ifrequently on the tonsils or arch of the palate ; and not un- 
frequently on the tongue, sometimes on its edges, and sometimes 
on the dorsal surface near its root. So constant was the appeai*- 
ance of these milk-like patches on one or other of these parts, 
that I was in the habit, latterly, of examining the mouth and 
throat first, after noticing the husky yoice of the patient, and 
ahnost imrariably was able to detect some patch which enabled 
me to prognosticate that she was affected with condyloma of the 
genital organs before an examination was made. And in cases 
of condylomata of the genital organs, where the mouth or throat 
did not present these appearances at the period of admission, 
they were not unfrequently apparent soon after during the pro- 
gress of the case. To this circumstance is to be attributed the 
fact to be immediately noticed, that in the journal of the cases 
rather less than one-half of the patients are noted as haying had 
the throat affected. 

In one or two instances only, and those were cases seen at an 
early stage of tihe affection, was the cutaneous eruption, de- 
scribed by Dr Wallace as a concomitant of the disease, obseryed. 
In those cases it presented the red-brown stain, the irregular 
form, and the tendency to scale off, or rather to desquamate, 
which seem to haye been regarded by him as characteri^ic. 

In only one instance did there exist a distinct condyloma in 
parts of the body other than those enumerated. This occurred 
in the case of a patient who presented a yery large condylomat- 
ous patch in the left axilla. 

Of the 36 cases, one or two were apparently complicated 
with syphilitic sores, as I was led to beheye by the production 
of a pustule after inoculation, which had the appearance of 
those produced by inoculation from the true syphilitic chancre ; 
others were complicated with gonorrhoea, as was preyed by the 
history of its inyasion and the appearances presented; and 



94 CONDYLOMA OR SIBBENS^ 

others were complicated with a leucorrhoeal discharge, as we 
ascertained by the use of the speculum. 

Of the whole cases, 20 were accompanied with gonorrhoeal or 
leucorrhoeal discharges from the vagina. Of the remaining 16, 
five presented ulcers seated on the 8urfsu5e of the condylomata, 
of which one or two were suspected, from the result of the 
inoculation, the pustule being destroyed with caustic on its 
appearance, to be syphilitic. The remaining 11 presented 
neither gonorrhoeal nor leucorrhoeal discharges, nor ulcers, but 
were simple cases of condyloma. Of these 11, three were wn- 
doubtedly first affections, the girls not having had any previous 
venereal complaint. In five of them at least, I ascertained with 
as much certainty as the evidence of such patients admits of, 
that the disease commenced with the formation of the condylo- 
matous patches or tubercles, and was not preceded by any sores 
or discharge, either mucous or purulent. 

In 16 out of the 36, the throat is stated in the journal to 
have presented the characteristic appearance ; but in nearly all 
the remaining cases the lips, mouth, or tongue, presented the 
condylomatous patches. These were most frequently seated in 
the angle formed by the commissure of the lips, occasionally on 
the inner surface of the hp or cheek. Those seated in the 
angles of the mouth appeared shghtly excavated, and would in 
all probability have been described as ulcers by most observers, 
but they all presented the characteristic white or milk-like 
coating on the surface. 

One patient was affected with iritis during the progress of 
the cure ; two with inflammation of the lymphatic glands in the 
groin. Besides the oases referred to where the eruption de- 
scribed by Dr Wallace was preswit, one was affected with 
clustered lichen, one with rupia, and one with psoriasis venerea. 

In 23 of the cases the duration of the disease, previous to ad- 
mission into the hospital, was ascertained, and was as follows : — 

7 
2 

1 

2, 
and in one case eight months. 

The longer duration of the disease, previous to admission, 
did not apparently, costeris paribus, render the cases materially 
worse than many which were of shorter duration, nor make the 



DoHition. 


Cases. 


Duration. 




2 weeks in 


3 


2 


months in 


3 


3 


3 


••» 


4 


4 


4 


... 


6 


4 


5 


••t 



A PRIMABY FORM OF VENEREAL DISEASE. 95 

C5tire more tedious. Of the two cases of five months' duration, 
oxie was cured in fourteen and the other in nine days. Two of 
^1:1.6 cases of two months' duration were cured in fourteen days, 
stxid one of the cases of three months' duration in seven days. 

One or two of the patients were discharged for misconduct, 
some at their own request, and some remained under treatment 
skM^ the date at which the report terminates ; but of the remain- 
ixig cases, 27 in number, the average duration, i. e. the term of 
tireatment until they were discharged cured, was twenty-two 
days. Of these, two were in the hospital above two months, and 
^ight between thirty and forty-five days, and in all of these cases 
ttke patients laboured under chronic discharges from the uterus 
ox- vagina, cutaneous eruptions, or ulceration of the throat. The 
^"verage duration of the treatment in cases not affected with 
"tiliese complications was twelve days. 

My treatment consisted chiefiy in the application of stimu- 
l^^nts to the condylomata ; the use of astringent injections and 
^^old washing, for the cure of the vaginal and uterine discharges ; 
^'Xii in cases of the latter kind, the internal administration of 
"^^i^icture of cantharides. In several cases, when there existed 
pvitaneous eruptions, the iodide of potassium was given. In no 
^^■^istance was any mercury administered, except in the case of 
^lie woman affected with iritis. 

The local application which I have found most advantageous 
^ the sulphate of copper. The condylomata were rubbed pretty 
ft:"eely with a crystal of this salt, moistened with water, every 
Second daj, and in some cases daily ; and a lotion of it, containing 
tw^o or three grains in each ounce of water, was kept applied by 
the patient. Under this treatment the condylomatous excres- 
cences disappeared with remarkable rapidity. In the cases 
^here there were ulcers suspected to be syphilitic, these were 
touched occasionally with the nitrate of silver. The patches in 
the mouth were repeatedly touched with the sulphate of copper 
Or nitrate of silver, more frequently with the former, and 
disappeared with equal rapidity with those on the labia and 
perinaBum. 

Although the treatment in the Lock Hospital has been thus 
almost exclusively local, in such cases, for six or seven years, 
I have not remarked any tendency in the disease to recur after 
having been cured by this simple method of treatment; nor 
have the patients, although many of them have been imder 
treatment for* subsequent affections, presented any secondary 



96 CONDYLOMA OB 8IBBENB, 

symptoms, except occasionally some of the emptions mentioned 
in the preyious description. The facility with which the cases 
under my care were cured, I attribute, in a good measure, not 
only to the effect of the remedies employed, but to the altered 
habits and circumstances of the patients. The regularity of the 
diet, the plain and wholesome food, the suspension of the uni- 
versal habit of drinking, the attention to cleanliness, the rest 
enjoyed, and remoyal from night air, constant exposure, excite- 
ment, and fatigue, must in themselyes, contrasted with the usual 
habits of prostitutes, tend to produce a marked effect on the 
diseases under which they may labour. 

The obseryations recorded in the preceding pages haye led 
me to the conclusion that this affection is a primary form of 
venereal disease, and that it is identical with sibbens. 

With respect to the first opinion, I must admit that it is ex- 
tremely difficult to obtain complete satisfaction, in the class of 
patients among whom I haye studied this affection, as to the 
absence of any previous disease, gonorrhoeal or syphilitic. Of 
the eleven cases which I have mentioned as having neither ul- 
cers, gonorrhcBa, nor leucorrhoaa, after repeated examination and 
cross-questioning, I was only able to satisfy myself that the 
disease had made its first appearance in the form of a condylo- 
matous tubercle, without any previous ulcer or discharge, in five 
of the patients. In three of the cases, the patients were un- 
doubtedly labouring under a venereal'affection for the first time. 
One of them, indeed, was under ten years of age. She pre- 
sented a condyloma on the right labium, the surface of which 
was ulcerated, or rather vesicated, another on the verge of the 
anus, several patches on the tonsils, one on the lips, some of 
considerable size on the tongue. The disease was contracted by 
sexual intercourse. A companion of this girl, under eleven 
years of age, was similarly affected, although to a much greater 
extent, and in her the disease was contracted from the same 
source. 

I was at one time strongly inclined to believe with Dr Hibbert, 
that this disease was *' the engendered product of rank unclean- 
Uness,"* for it is certainly most frequently met with in patients 
of the lowest class, and is generally accompanied with profuse 
and neglected discharges. But the number of cases in which I 
have seen it where there was no such discharge, have satisfied 

* Edinburgh Journal of Medical Science, 1636s 



A PRIMARY FORM OF VENEREAL DISEASE. d7 

me that this is not the sole cause, although it may be admitted 
that under its influence the disease is fostered and dereloped. 
My opinion on this point exactly coincides with that of Dr 
Wallaoe. '' The want of habits of cleanliness/' he observes^ 
'' has a great influence in determining the formation of fungi, of 
rhagades, and perhaps of onyxis. In fact, these symptoms are 
often produced by the dirty habits of patients, when the opposite 
habits wouM hare prevented them. I do not, however, say that 
they never occur except in such habits, for I have known very 
cleanly persons to have the condylomatous form of disease."* 

The invariable affection of the mouth and throat at some period 
of the disease — ^for I am satisfied it is invariable — ^with the pecu- 
liar aad perfectly characteristic eruption, or condylomatous 
patches, in itself is sufficient to point out that this disease is 
«peca&e in its origin, and essentially different from any of the 
secondary symptoms which are known to result from the syphi- 
litic virus, or from any thing which can be produced by filth and 
gdnorrhcBa. 

To satirfy myself, if possible, of the specific character andccm- 
tagious nature of this disease, I inoculated in every one of the 
cases referred to from the matter, which can in general be scraped 
from tiie surface of some of the condylomata, or from the ulcers 
which they frequently present. The result of these experi- 
ments has be^i different from either that of Dr Wallace or M. 
Rioord, between whose results there also exists a remarkable 
diBcrepancy. 

Dr Wallace states, that in " two or three weeks after" [ino- 
culation], "the seat of the inoculation swelled and became 
somewhat red and painful. It then desquamated, or appeared 
scaly. The tumidness and scaliness increased. The scales then 
gradually became scabs or crusts, and the spot as gradually ac- 
quired a fungoid elevation. In a few instances the scaly 
tubercle, soon after its appearance, formed an ulcer. On other 
occa^dons parts of the fungous elevation ulcerated, and then its 
surface appeared depressed, or in wells. "| He adds, that the 
secondary symptoms followed, the skin presenting the rubeoloid, 
or the scaly, or the tuberculated eruption, and the mouth the 
superficial form of the disease. 

M. Ricord states, that in 221 inoculations from mucous tubercles 
or condylomata, no effects were produced in any case. 



• Op. Cit, p. 751. t <^P- Cit., p. 133. 



98 CONDYLOMA OR SIBBENS^ 

On comparing the results of M. Ricord's inoculations witli 
those of Dr Wallace, I was at first led to believe that the dis- 
crepancy was probably to be explained by the supposition that 
M. Ricord was not aware of Dr Wallace's experiments, or did 
not advert to the circumstance stated by him, that the inocula- 
tion did not take effect until two or three weeks afterwards, and 
that before that period he might have ceased to watch for any 
effects. The result of my own observations, however, is at 
variance both with this explanation and with the experience of 
Dr Wallace ; for in the only cases in which my inoculations suc- 
ceeded, the effect took place within one or two days. 

Of the thirty-six cases referred to in the preceding part of this 
paper, inoculation succeeded in only four cases. In all of these 
the first appearance presented in the seat of the inoculation was 
a pustule on the second or third day, as in inoculating from a 
chancre. Believing that this had been the case in the first two 
or three experiments, I destroyed the pustule with nitrate of 
silver. In the fourth case I sdlowed the two pustules which 
formed to run their natural course; a scab formed, which 
appeared to be seated on sores depressed below the level of the 
adjoining surface, but without the elevated or hardened edges, 
or the defined circular form of chancre. They continued in- 
creasing in size, preserving the same appearance and covering, 
until they met each other and coalesced. On the fourteenth 
day after inoculation the crusts became detached, and a fungoid 
excrescence, having all the appearance of a condyloma, shot up 
from the sore. This was destroyed. 

In another case, not included amongst the thirty-six referred to, 
inoculation produced the same effects as those last described; 
and the sore now presents a small fungoid elevation of the skin, 
somewhat resembling a condyloma. In addition to the results 
derived from direct inoculation, I may add, that I have had fre- 
quent occasion to remark the existence of a condylomatous 
tubercle on opposite surfaces of the thighs, at points exactly cor- 
respondmg, and brought in contact when the thighs were 
approximated. 

These results are as yet imperfect and unsatisfactory, but so 
far as they go, they are confirmatory of the observations of Dr 
Wallace, in as far as regards the appearances presented, although 
they are at variance with his results, both as regards the 
pustular form which preceded the scab and tubercle, and the 
period at which the inoculation took effect. 



A PRIMARY FORM OF VENEREAL DISEASE. 99 

That inoculation took effect in so few of the cases experi- 
mented upon by me, may be explained, perhaps, partly by the 
fact that I selected a part of the thigh where condylomata are 
yery seldom produced in the natural course of the disease, and 
j)artly, it may be, by my not having had recourse to any means 
to prevent the patient washing the inoculation immediately 
after it was done, to prevent its taking effect. Dr Wallace 
states that his inoculations succeeded much less frequently than 
inoculations from chancres. 

The inference to be deduced from the experiments referred 
to, more particularly those of Dr Wallace, appears to me to 
afford strong corroborative evidence of the opinion which I have 
formed, that this affection is specific, and one of the primary 
forms of venereal disease. 

The identity of this disease with the affection called sibbens, 
which at one time ravaged this country to a great extent, and is 
now generally believed to be nearly extinct, or confined to some 
limited localities in the west and north of Scotland, is, I think, 
very clearly made out by a reference to the descriptions of it 
which we possess. This question, or the question of the venereal 
origin of sibbens, is not likely to be encumbered now with argu- 
ments founded upon the possibility or impossibility of curing it 
without mercury, any more, I trust, than the syphilitic nature 
of any of the diseases met with in the Lock Hospital is to be 
doubted because they have been treated and cured there without 
any mercury for the last six or seven years. The question will 
be determined by the anatomical characters of the disease. 

Dr Gilchrist, in an account published in 1766, of sibbens as it 
appeared in Scotland at a time when it was very prevalent, says, 
" It first appeared here in the form of a sore throat, or an in- 
flammation of the uvula or pap of the hawse, as it is termed, 
and neigbbouring parts. The tonsils were often superficially 
ulcerated, appearing either raw or covered with a white slough. 
Frequently there was a thrush, that is, white specks and sloughs, 
npon the roof of the mouth and inside of the cheeks and lips, 
which commonly showed itself at the corners of the mouth, in a 
»rmll rising of the skin, of a pearl or whey colour" * ♦ • 
" Sometimes there was a hoarseness." — " Scabby eruptions were 
often met with on the scalp, forehead, inside of the thighs, 
groms, and parts contiguous." — " The whole surface of the body 
appeared mottled or flaked, of a dusky copper colour, or dirty 



100 CONDYLOMA OB SIBBENS, 

red." — '' Inflammatios, sorenesses, and excrescences about the 
fundament were frequent."* 

In an account of the disease '' falsely called the yaws in the 
south of Scotland, and eibbens in the north," hj Mr James Hill, 
surgeon in Dumfries, written in 1768, after referring to the 
Terrucfo, condylomata, and tubercles met with on the perinaeum,* 
scrotum, and various parts, and citing the descriptions of Dr 
Harvey, Wiseman, Turner, Dr Barrie of Cork, Van Swieten, 
Plenck (all whose cases, he says, are sibbens), and Boerhaaye, 
to show that the distemper called venereal syphilis or French pox 
in France, Germany, Holland, England, and Irelaad, is the same a» 
the Scotch sibbem, he describes its s^pearance in the mouth in the 
following graphic terms : — " When the infection is ccnnmunicated 
by a foul pipe or spoon, the angles of the mouth, the lips, gums, 
&c., are first affected. The first appearance of an ulcer <m the 
lip, &c., exactly resembles a bit of fine white soft velvet pasted 
upon the skin ; for it will not wipe off. But after it has eaten 
in for some time, it then has the appearance of a piece of the 
red skin cut out, and a white velvet patch put in its place. 
These ulcers spread broader than deep."t To prove its identity 
with syphilis, he rdTers to a case of ''clap" in afemale, ''attended 
with verrucfe, which she called haemorrhoids," and who communi- 
cated sibbens to nine of his own relations. 

Dr Adams visited Scotland, as a '^ means of assisting his inquiries 
into morbid poisons," for the express purpose of examining the 
sibbens, believed then, as it still is, to be prevalent only in the 
south-west of Scotland, The description of the patients whom 
he saw confirms the opinion which I have formed of the identity 
of the diseases. One female had lost her uvula and tonsils, her 
voice was affected, and, adds Dr Adams, " the loss of substance 
about the lips is very trifling, but the edges are covered with an 
opaque white cuticle, apparently newly formed." * * « 
^' She had at one time complaints about the anus." Of anoAer 
female whom he examined, be says, ^' The uvula and tonsils were 
suffiised with a viscid mucus, and in some parts covered with the 
white appearance before mentioned. The soreness extends from 
the edge of the lips along the inside of the cheek and side of the 
tongue ; but if there be ^y loss of substance, it is only at the 
uvula and tonsils, which appear rather wasted than ulcered." 

• Phytical and Literaiy Bsgays, vol. iii. p. 154-177. Edinburgh, 1771. 
•f- Cfiies in Surgery, by Jiimes Hill, Surgeon, p. 258. Edinburgh, 1772. 



A PRIMARY FORM OF VENBREAL DISEASE. 101 

She bad also a cutaneous eruption, of which Dr Adams says : 
'' These are small elerations above the cuticle ; she showed me 
some on her legs and arms, which seemed pustular, but were 
quite dry."* Other cases are referred to of a similar kind, from 
a review of which he arrives at the conclusion, that sibbens is 
different from the venereal disease. Its prevalence in Scotland 
is explained by Dr Adams by reference to the habit, which, he 
says, was peculiar to some districts of Scotland in those days, of 
smokiog out of a common pipe — of *^ using a single pipe for a 
whole family, and almost for a whole village" I The tradition, 
regarding the origin of the disease in Scotland was, that Crom- 
well's soldiers had introduced it and the smoking of tobacco at 
the same time, by means of their pipes. 

The idea generally entertained of this disease by, I believe, all 
who have written on the subject, in common with Dr Adams and' 
the writers referred to, that it is communicated by kissing, or by 
driilking out of the same vessel or smoking out of the same pipe, 
I am inclined entirely to discredit. I behove it has arisen, along 
with the idea that this is a disease which chiefly or solely, in 
some instances, affects the mouth, from the &ct that in every 
case the mouth is more or less affected at the same time as the 
genital organs. The affection of the mouth is one of the consti- 
tutional effects of the disease, to be observed, I believe, in every 
case of condyloma at some period of its course. And I have 
little doubt that the erroneous ideas generally entertained re- 
garding the nature and mode of propagation of this disease, have 
originated in the desire on the part of those affected with it to 
conceal the real origin of their complaint. Had the genital 
organs been examined in every case where the mouth was affect- 
ed, I behove the medium of contagion would have never been 
suspected to have been merely kisses, tobacco pipes, or common 
drinking cups. 

Mr Carmichael, believing with Dr Adams that this disease 
was endemic in Scotland, particularly in the western part of it, 
conjectured that it must be frequently transmitted to Ireland, 
and accordingly he recognised its frequent, almost daily, occur- 
rence in the Lock Hospital of Dublin. These were undoubtedly 
cases of condyloma, and not more pecuhar to Dublin, if the 
account given by Dr Wallace of his exanthematic syphiUs is 
correct, than to the west of Scotland. 

* On Morbid Poisons^ by Joseph Adamsy M.D., p. 183-8. London, 1807* 



102 CONDYLOMA OR SIBBENS, 

The limits of this paper prerent me from endeavouring to 
trace the identity of this disease with the renereal affections de- 
scribed by the older writers, but I cannot avoid remarking that 
one can scarcely refer to any old work on syphilis without a con- 
viction that it has been very generally described and confounded 
with syphilis. To take e. g. at random a single observation from 
a small work by Dr Saunders, to which is appended the tract 
by Professor Plenck on the action of mercury on the salivary 
glands : " A child of a year and a half old, whose parents were 
not venereal, had for half a year condylomata about the anus, 
rhagades, and small ulcers in the angles of the mouth,*' &c.* 
One can hardly resist the conclusion, that a more careful exami- 
nation of the subject will show that sibbens is as familiar as 
syphilis, and as httle peculiar to certain localities, and that it has 
been overlooked or ascribed to the secondary effects of that 



The most recent account of sibbens, as it prevails in Ayrshire, 
Galloway, and Dumfriesshire, is contained in a very interesting 
paper by Mr Wills of Cumnock, published in April last,f which 
I have just seen for the first time. On perusing it I was grati- 
fied to find all my preconceived opinions, regarding the identity 
of the condylomay daily met with here, with the sibbens of the 
west, confirmed and verified. The appearance of the tubercles, 
or condylomata, on " the tongue, cheeks, angles of the mouth, 
anus, groins, and genital organs," and of the cutaneous eruption 
or secondary symptoms, given by Mr Wills, is exactly applicable 
to the cases daily seen in the Lock Hospital of this place. While 
I differ from him regarding the necessity for the use of mercury 
in the cure of this disease, and regarding the mode in which the 
affection of the mouth is produced, his views entirely coincide 
with mine on most of the other points of interest. ** Between 
sibbens," he says, " and the venereal condyloma, there does not 
appear any difference ; and I will be much astonished indeed if, 
on farther inquiry, the latter is not found to be often communi- 
cated by the mouth. Whether sibbens may have wandered from 
our mountains to the cities, or venereal condyloma from towns to 
us, is not for me to decide." 

Mr Wills recognises the resemblance between sibbens and 
the disease described by Mr Johnson as venereal condyloma, 

* A New and Easy Method of giving Mercury, Slc, by William Saunders, 
M. D., p. 83. London, 1768. 
f London and Edinburgh Monthly Journal of Medical Science, April 1844, p. 282. 



A PRIMARY FORM OF VENEREAL DISEASE. 103 

in such terms as to satisfy me that little remains to be done to 
establish the identity of tHe two ; although I am still inclined 
to believe that the idea of the Cumnock disease being propagated 
bj contact of the lips or tobacco pipes is fanciful, and founded 
upon a limited view of the constitutional symptoms of the 
affection. " Mr Henry James Johnson, in the April number 
of the Medico-Chirurgical Review for 1834, in giving an ac- 
count of this fungoid venereal sore, under the name of venereal 
condyloma, has presented so minute and faithful a description 
of sibbens, as it at present exists in this part of Scotland, as 
almost to make me doubt if that gentleman had not his model 
from Ayrshire, with this difference, that what he calls a secon- 
dary affection is our primary. This is easily accounted for. 
Mr Johnson ha^ been in the habit of seeing the disease in the 
form it assumes when got by coition ; we again commonly meet 
with it as caught by contact of the lips, or through the medium 
of tobacco pipes, &c. Sibbens, however, are frequently com- 
municated by coition ; and then the disease has all the characters 
of venereal condyloma." And again, " Their appearance on the 
female parts of generation is so accurately described by Mr 
Johnson, that I would only be copying that gentleman's words 
in attempting a description ; but I may take this opportunity of 
stating, that sibbens caught by coition are not always accom- 
panied with gonorrhoea, and are oftener without than with that 
discharge, particularly in males." 

From the preceding observations and experiments, I think 
myself warranted in deducing the following conclusions as highly 
probable if not completely substantiated : — 

1. That condyloma is a primary form of venereal disease — 
specific in its characters and its origin, and distinct from 
gonorrhoea or syphilis. 

2. That it is identical with the disease described under the 
name of sibbens or sivvens. 

3. That it is communicable by contagion and inoculation. 

4. That the difficulty of producing it by direct inoculation, 
and the similarity of the affection of the mouth in eases pro- 
duced by sexual intercourse with that in which it has been 
supposed to be produced by contact of the lips, &c., render it 
probable that the affection of the mouth is always a constitutional 
symptom resulting from a venereal origin. 

5. That it is curable without the use of mercury. 

Before concluding, I take this opportunity of acknowledging 



104 DEATH BY RUPTURE OF THE LUNG 

mj obligations to Mr Benbow, the present active and intelligei^ 
house-surgeon to the Lock Hospital^ for the efficient assistance 
which he rendered to me in the investigation of this subject, in 
the cases referred to as reported and experimented upon there. 



Case of Death by Rupture of the Lung from Violenee withofut 
Injury of the walls of the Chest. By William Tait, M.D., 
Surgeon to the Edinburgh Police. 

On the 18th of March last, I was called about noon to the West 
Port, to see a girl who was reported to have been run over by 
a parcel-van, and to have received considerable injury. Having 
acddentally met a medical friend on the street, I requested him 
to accompany me, and we examined her together. She appeared 
an interesting child, about three years of age, well formed, 
plump, and healthy. 

The clothes having been previously removed, every part of 
the body was carefully examined, and no external injury was 
observed, with the exception of a slight abrasion of the cuticle 
over the deltoid muscle of the left arm, and a faint livid line, 
about an inch broad, extending from this to within two inches of 
the elbow, and a spot of ecchymosis, about two indies square, 
over the crest of the left ilium. The breathing being much af- 
fected, and considerable pain being produced by a full inspiration, 
our attention was specially directed to the state of the ribs and 
the vertebral column, but not the slightest crepitus or other in- 
dication of fracture could be discovered. 

She was reported by the parents to have been spitting blood 
before our arrival, but we had no positive evidence that this had 
come from the lungs, and were of opinion that it had flowed from 
a slight bruise of the gums, from which blood still appeared to 
be oozing. On applying the ear to the left side of the chest, a 
combination of the mucous and crepitating rattles was distinctly 
perceived, and we considered it probable that the lung had sus- 
tained some injury, but were not inclined to view it as of a very 
serious nature, as the wheel of the van did not appear to have 
passed over the chest. 

The child was put under the charge of the medical attendant 
of the family, was freely leeched on the chest, but died on the 
evening of the following day, about thirty-five hours after the 



FROM EXTERNAL VIOLENCE, 105 

acddent^ — ^haying for seyeral hours before death expectorated a 
eonsiderable quantity of blood. 

The drirer of the Tan having been apprehended on a charge 
of carelffls driving, Dr Weir and I, by virtue of a warrant from 
the ma^stratefi of Edinburgh, made a post-mortem examinatioa 
of the body on the afternoon of the 20th, the day after death. 
The traces of ecchymosds, on the external aspect of the left arm, 
aad on the crest of the le£b iUum, were then more ^stinct than 
when examined immediately after the acddenk had occurred, but 
no additional mark of extenial injury was observed. On laying 
op^ the different cavities, the brain and abdominal viscera were 
foimd to be quite healthy, but more blanched than usual. The 
left cavity of the chest contiuned fully a pound of fluid venous 
blood, and the lung was considerably collapsed. There was a 
rapture of the left lung fully four inches in length, commencing 
aWt the middle of the anterior margin of the superior lobe, 
and extending across the lung. From the inner extremity of 
the wound a second rent, about two inches in length and more 
snperfidal than the former, extended forwards in the direction of 
the margin without reaching it, so as to give to the rupture the 
form of the letter V. The portion of lung situated between the 
extremities of the letter was ahnost detached, and turned back in 
SQch a way aa to appear at first sight altogether unconnected with 
it. A eonsiderable quantity of blood was found effused into the 
parenchyma of the lungs, and also into the bronchi. Lymph waa 
effused upon the surface of the pleura pulmonalis ; and a circular 
patch of ecchymosis was observed upon the external surface of the 
pericardium, corresponding with the left ventricle of the heart. 

From these appearances, we gave it as our opinion that the 
duld had died from the loss of blood, consequent upon the lesion 
rfthe lung ; and that this injury itself was probably the result of 
severe pressure, appUed externally at the moment of a full iu- 
q)irati0n. 

Whether the opinion fifl to the cause of death, or the manner 
in which the wound of the lung had been produced, be correct 
or not, this case is interesting in its medico-legal bearings, in so 
iar as it oonfirms the fact, already ascertained, that there may 
be fatal lesion of an internal organ from force applied externally, 
while not the slightest indication of violence can be observed on 
the surface of the body. Cases illustrative of internal rupture 
without outward mark of iqury, are related by Drs Geoghegan, 
Watson, Williamson, Henke, Taylor, &c. The abdominal viscera^ 



106 DEATH BY RUPTURE OF THE LUNG 

however, appear to suffer more frequently in this way than the 
lungs. In the latter it is comparatiyely rare, as might be anti- 
cipated from their being better protected, and their peculiar tissue 
being less Ukely to suffer from pressure than any other organ 
contained in the body. From experiments made upon the lungs 
of animals, we are satisfied that very severe pressure will not 
produce a rupture of these organs, and that some other agent 
must have been called into operation to produce it on the occa- 
sion referred to. The part of the lung injured appeared to havQ 
been compressed or twisted between the opposing forces. Had 
it been possible for a part of it to have become wedged between 
two of the ribs, it would at once have explained the mode in 
which the injury had been inflicted ; but conceiving this to be 
physically impossible, any suggestion which we are prepared to 
advance in order to account for it must be very unsatisfSEtctory. 

A case came under my notice in May 1843, of a woman who 
died from rupture of the spleen and effusion of blood into the 
peritoneum. Both she and her husband were much intoxicated, 
when a quarrel ensued. The husband attempted to kick her, 
and she fell on the edge of a table. She died three days after. 
On an examination of the body, no marks of ecchymosis were 
observed but on the arms and shins. When the abdomen was 
opened, coagula of blood were found floating amongst a quantity 
of serum, and coagulable lymph in the cavity of the peritoneum^ 
which were discovered to have come from a rupture of the spleen 
and its peritoneal covering, about three inches in length. 

NOTE BY THE EDITORS. 

As remarked above, the rupture of the lung is much more 
rare, under such circumstances, than that of the heart and abdo- 
minal organs. 

Dr John Gairdner of Edinburgh, in the Edinburgh Medico- 
Chirurgical Transactions, reported an interesting case, where 
the injury arose from the wheel of a loaded cart, as in the above 
instance. The accident occurred in a girl ten years of age, and 
her death was immediate. " There was scarcely any percep- 
tible trace of the impression of the wheel externally, and no 
subcutaneous extravasation, except a very shght one under the 
left nipple. 

" In the thorax, the only deviation from the healthy state was 
the rupture of the heart, with extensive laceration of its sub- 



FBOM EXTERNAL VIOLENCE. 107 

stance. Both ventricles and both auricles were laid open by the 
laceration, and the septum was torn to shreds. About one-half of 
the substance of the heart had burst a way for itself through the 
pericardium into the right cavity of the thorax, where it was 
found immersed in a very large quantity of grumous blood, and 
still attached to the other parts by means of a small portion near 
the apex, where the rent had stopped."* 

Notwithstanding the extent of the rupture, as in the above 
case, there was hardly any mark of hurt externally, and no rib 
was in the slightest tlegree injured. 

This case at first sight appears to come very close to that 
above reported ; but while there was rupture of the heart, the 
long appears to have been uninjured. And a considerable num- 
ber of cases besides are recorded, in which the heart was rup- 
tured under similar ch*cumstances. 

The liver, the spleen, the kidney, the intestines, have been 
also frequently ruptured by external violence without any marks 
of injury on the surface. But authors appear to have been 
rather rash in stating the same to be true of the lungs. It seems 
likely that the lung cannot be ruptured under such circumstances, 
or without fracture of the ribs, except in very young children. 
We cannot call to mind a distinct case of rupture of the lung 
anywhere recorded similar to that above reported. And on 
closer inspection, those commonly referred to under this head 
will be found to be less cases of rupture than of wound. Beck, 
whom nothing in general escapes, refers to the Medical Gazettef 
alone for evidence of rupture of the lung without external ap- 
pearance of injury ; but the writer in the Gazette, in the case 
alluded to, refers the breach in the lung to perforation by a 
fractured rib. Again, one of the writers in the Gazette refers 
to Morgagni for a case of the same kind. But Morgagni does 
not state what the condition of the surface was, and describes 
the ribs as being extensively depressed and fractured, at the 
same time that there was an aperture in the lung.^ Morgagni's 
case may be a case of rupture, but the evidence afforded in the 
report is far from satisfactory, 

* Edinbnrgh Medico-Chinu^cal Transactions, toL i. p. 662. 

t Vol XV. pp. 668, 727, 729. 

t For some valuable observations on the conditions under which blows produce 
different effects, see the << Medical Jurisprudence of Blows and Contusions,** Pro. 
bttioDsiy Essay, by David Skae^ F.R.C.S.E. 1836. 



108 CU6ABIUTY OF BYPBOOEPHALUS. 



On the ready CurabUihf of the mare acute Form of Hydro- 
cephalus, i/n its earliest Stage, under aicdve Treoitment; wUh 
a Case. By Alexander Harvet, M.D., Lecturer on the 
Institates of Medidne in Marischal College aad Uniyerfidty, 
Aberdeen. 

It is on all hands admitted that the acute hydrocephah» (using 
that term m equivalent to acute inflammation and ita effieets, of 
the brain or its membranes) shows little err no tendency to a 
spontaneous favourable termination, and very quickly passes into 
a state which, although not absolutely intractable by remedies, 
nor inevitably fatal, is yet very litde under their control, and 
Tery seldom recovered from. 

There is considerable difference of opoion, however, as to ti^ 
degree in which it is amenable to remedies within die first two 
or three days from its outset. Formerly, when as yet the true 
nature and the proper treatment of the disease were unknown or 
imperfectly understood, it was very generally beheved that ev«i 
at that early period the genuine hydrocephalus is singularly litde, 
if at all, susceptible of the influence of remedies of any kind. 
This persuasion, however, of its peculiar obstinacy does not now 
obtam, at least to that extent, or is entertained by comparatively 
few, and the greater part of the profession seem to look upon it 
as neither so intractable nor so fatal as it was viewed by the first 
writers on it. 

But this mere general admission in favour of the curaKlity of 
the disease is made with very different degrees of readiness by 
differ^it practitioners. Some very competent observers seem to 
be decidedly of opinion that, within the period specified, the 
more acute and well-marked form of it yields comparatively 
readily to active treatment, particularly cojrious and repeated 
blood-letting and full purging ; and to have satisfied liiemselves 
of the actual accomplishment of a cure> in thdbr own practice and 
under such treatment, in a considerable proportion of cases, or 
even in the great majority of cases. 

I apprehend, however, that the great bulk of <ite profession 
have no such lively persuasion of the curability of the disease, 
nor any such confidence in the efficacy of treatment, even in its 
more acute form and in its earliest stage ; and that it is a fair 
account of their experience to say, that, of the cases of that kind 
seen by them from the commencement and then brought under 



CURABILITY ,OF HYDROCEPHALUS. 109 

treatanent, although more or fewer of th^i rfecoyer, the larger 
proportion terminate fatally. 

And there are still, as formerly, not a few, though few oom'«> 
paratively, who hare either strong misgivings w are positively 
sceptical as to the curability of the genuine hydrocephalus at any 
period or in any form. Their own experience of it has, perhaps, 
been so uniformly unfavourable as to have created or strength- 
ened a conviction in their minds of its being almost necessarily 
&4al ; and so strong is that conviction, tiiat tbey do not hesitate 
eonfidently to avow their belief that those of a contrary persuamoii 
are either singularly credulous, or greatly deceive themselves in 
regard to the evidence on which that persuasion is founded ; and 
that l^e cases adduoed by them as examples of hydrodephaluB 
dared in its earliest stage had not been cases of that disease ait 
all, and are '^ remarkable only for thdr singular resemblance to 
it.'' 

And therfe is yet another, and perhaps a still larger class of 
practitioners, who do not question abstractly the curability or 
er&i the ready curability of this disease during the diort period 
specified, but doubt or deny the possibility of recognising it at 
that time, except in a very few cases, with su^ient certainty to 
warrant active interference, and condemn perhaps, or at least 
practically disregard, the principle of being guided in the treat- 
ment of doubtful cases by probabilities of a low kind as to tbdr 
real nature. In regard to many of the cases which come before 
them, they may from the first have strong suspicions — suspicions 
which are often painfally justified afterwards ; but they do not 
feel themselves called upon, on the fsdth of these, to subject 
their patients to the active treatment which tliey would at 
once adopt were they fiilly satisfied that they were labouring 
under actual hydrocephalus. Their experience of the disease, 
accordingly, is perhaps as unfavourable as that of the preceding 
class ; but they attribute their want of success, not to any pecu- 
liar obstinacy in the disease to the influence of active treatment, 
but to the impossibility of making out the diagnosis in its early 
stage. 

Nothing is more certain than that the settled convictions of 
our minds in regard either to the curabiUty of the disease or the 
diagnosis of it, in its early stage, will very materially influence, 
though insensibly it may be to ourselves, our conduct in this 
department of practice. And, accordingly, it will be found, I 



110 CURABILITY OP HtDROCBPHALUS. 

apprehend, that those who entertam a confident persuasion of 
the ready curability of the disease, at the period and under the 
treatment already mentioned, and are impressed with the impor- 
tance of being satisfied, in judging of the diagnosis, with indica- 
tions much short of certainty, are at once prompt and energetic 
in their practice ; that those who are more or less sceptical as 
to its curability, or require rather clear evidence of its existence, 
are so far influenced thereby, in cases at least which are at all 
doubtful, as to decline or defer any very active or decided prac- 
tice; and that those who, though agreeing generally in the 
views of the former class, are less confident in their apprehension 
of them, and less sanguine as to the general elBicacy of bold and 
energetic practice, are proportionally less prompt and decided 
in their treatment. 

And what if the views of the first class, and their statement 
of the successful results of practice, are well foimded ? What if 
it be true that hydrocephalus, in its more acute form and in its 
earliest stage, is readily amenable to active treatment, and that 
its diagnosis may in general be then made out with sufficient con- 
fidence to warrant such treatment ? And what if the views of 
the others are erroneous, and their unfavourable experience of 
the disease attributable to inefficient practice, or to active prac- 
tice either too long deferred or carried to a degree short of what 
the disease requires? These are obviously questions of the 
utmost practical importance. 

Being myself satisfied that the evidence adduced and relied 
on by those who believe that these questions admit of an affirma- 
tive answer, has stronger claims on our consideration than many 
suppose, or at least that '^ it is not so clear a case that there is 
fwthvng in it,'* I think it might not be amiss, for the sake of 
those who have never carefully examined it, to lay that evidence 
formally before them, and to urge upon them whether, if, upon 
a due consideration of it, it shall not appear altogether satisfac^ 
tory to their minds, it is not, at all events, such as to require of 
them a line of conduct nearly, if not exactly, the same as if it 
were in the highest degree conclusive ; and whether, also, it is 
not our duty, in deaUng with a disease of so intractable a cha- 
racter when fairly established, and so hopeless when left to itself, 
to act in doubtfid cases upon indications of a slight nature, and 
on low probabilities as to their curability in all cases, and not de- 
cline or defer the adoption of active treatment till we have some 



CURABILITY OF HYDROCEPHALUS. Ill 

sort of certainty as to the nature of the cases on the one hand, or 
on the other, clearer evidence than yet appears of the efficacy of 
such practice. 

It is certain, indeed, that if we are habitually guided in our 
treatment of this class of cases by such principles as these, " it 
will be impossible for us to say how many of those cases which 
under active treatment terminate favourably, would otherwise 
have ripened into well-marked hydrocephalus ; and we must be 
content to have it said, without its being possible for us to 
refiite the assertion, that not all of the disorders which we 
treat as acute hydrocephalus are really instances of that com- 
plaint."* Nay, doubtless, it must happen that, acting on such 
principles, — guided often in a great measure by conjecture, — 
" not waiting till the nature of the symptoms demonstrate that 
the malady is present, while they demonstrate also, at the same 
time, that it is well-nigh hopeless,"t we shall occasionally sub- 
ject patients to a plan of treatment which, could we get behind 
the scenes, we should perceive to be unnecessary. But in regard 
to this disease, it is especially important to remember that 
'''probability is the very guide of lifCy^X and that "in those 
diseases in which most can be done by art, our practice must 
always be guided in part by conjecture, because, if we wait for 
certainty, we very often wait till the time for successful practice 
is past."§ And, if err we must at times, better far the re- 
flection, at the close of our professional life, that if chargeable 
in this particular instance with the nimia cura medid, we 
have at least lost comparatively few cases of acute hydrocephalus 
seen by us from the commencement, than that of being guiltless 
in that respect, but of having lost many such cases. 

I propose, then, to state somewhat formally and in detail 
the evidence in favour of the beUef which is entertained by 
some very competent authorities, that the hydrocephalus, in its 
more acute form, is, in its earliest stage, very generally amen- 
able to active treatment, and that the diagnosis of that form of 
it may generally be made out at that stage with sufficient con- 
fidence to warrant active interference. 

I must defer doing so, however, till a future occasion, and 

• Watson's Lectuieu on the Practice of Physic, p. 428. f Ibid. 

t Batler's Analogy, Introduction. 

§ Alison, History of Med., Cyc of Prac Med., yoL L p. IzzzTiL 



112 CURABILITY OF HYDROCEPHALUS. 

'will in the mean time conclude tibese remarks with the following 
case, which fell under my care yery recently, and which in my 
opinion admirably illustrates the force of them. 

Case. 

A young gentleman, setat . fourteen, one of a family of whom three 
had died of hydrocephalus, and himself sufficiently remarkable 
for the '' acuteness of his senses, and the activity of his mental- 
powers of observation and apprehension," so often seen in the 
victims of that complaint, — after being confined to the house 
for some days on account of a slight cold, began to complain 
the week following of acute pain in one of his temples, attended 
with some quickness and sharpness of pulse at night. For 
these symptoms he was again confined to the house, and smartly 
purged. On the third day thereafter, the pain had considerably 
abated, and on the morning of the fourth he seemed to be quite 
well. 

On the evening of that day, however, the pain returned, and 
besides bemg as acute as formerly, now affected both temples 
and the forehead. On seeing him next morning, I learned that he 
had passed a restless night, and had been frequently wakened out 
of sleep by the severity of the pain ; and that the pain itself, 
while more acute than that of ordinary headach, darted at 
times through his head in stounds or twiages, was easiest when 
he lay quietly in bed, and much aggravated on moving his 
head or assuming the erect posture. His head felt sensibly 
warmer than natural, but there was no throbbing^ of the 
temples nor flashing of the face, and his pulse was tranquil. 
He had been much sickened by some medicine he had taken at 
bedtime, and had vomited several times in consequence ; and 
this was observable as the effect of the medicine he had taken 
in the earlier part of the week. 

These symptoms — especially the character of the pain — ^taken 
in connexion with his presumed tendency to hydrocephalus, 
seemed to me to warrant suspicion of their being dependent on 
incipient inflammation within the head. I therefore immediately 
bled him from the arm to the extent often or twelve ounces, with 
the effect of inducing faintness, sickness, and vomiting. Thereafter 
I had his hair cut short, and cold assiduously and effectually ap- 
plied to the head, and prescribed for him strong purgative 
medicme. The pain of the head was considerably relieved by the 



CURABILITY OF HYDROCEPHALUS. 113 

bleeding. The blood drawn was very distinctly buffed. The 
medicine sickened him a good deal, but purged hhn fully and re« 
peatedly in the course of the day. 

Next morning, the pain of head, though much easier, still 
continuing to come in stounds, I again bled him from the arm 
to the same extent, and with the same effect, as yesterday. 
This bleeding entirely and at once removed the pain. The 
blood was even more sizy than on the former occasipn, and 
much contracted. The purging was kept up briskly, and the 
cold applications to the head were continued. 

The pain did not again return ; he regained his strength 
ra|xdly ; and in less than a fortnight was allowed to resume his 
wonted occupations. 

The distinctly inflammatory appearsmce of the blood (trawB 
strengdiened my suspicion that the case was one of inflammation 
within the head, in its first stage ; and the rapid abatement of 
the symptoms consequent on the bleeding and purging, and the 
speedy convalescence, notwithstanding the weakening effect of 
Ihese, heightened it still more, as indicating that an inflammatory 
disease had been cut short,* 

Should any one, however, dispute the inference thus drawn 
as to the nature of the case, I shall not insist upon it. I at once 
admit th^t the inference is only a probable one ; and that, had 
the pain been more distinctly violent — shooting through the head 
with such intensity as to cause screaming — ^had there been marked 
sickness, and vomiting of all or nearly all ingesta, delirium, and 
quickness and sharpness of pulse, my own mind would be niuch 
b^ter satisfied in regard to it. I take leave, howeverj to re- 
mark, that ihe symptoms were precisely similar to those att^ading 
the commencement of many cases which have ended in fatal hy- 
drocephalus, and in particular to those described by Dr Aber- 
crombie as constituting his fourth and fifih variety of this class 
of head affections ; and that, unless such a one is disposed to deny 
the inflammatory nature of that disease, or, admitting this, to 
deny the curability of it, even in its early stage, he cannot surely 
i^fiise allowing, that the whole circumstances of the case were 
such as not only to justify the treatment adopted, but imperatively 
to demand it. 

Ab£ai>eek, Majf 17> 1844, 



* Brit and For. Med. Renew, toL ui. p. 307. 



114 UNUSUAL TERMINATION OF A CASE 



Unusual Termination of a Case of Congenite Hydrocephalus. 
By William Campbell, M. D., Lecturer on Midwifery, and 
Consulting Physician- Accoucheur to the Maternity Hospital, 
Edinburgh. 

Mrs Brown, set. twenty-two, healthy, among the industrious 
classes, produced, on the 2d of April of this year, in her second 
confinement, a large female foetus affected with hydrocephalus. 
The male parent was healthy, and twenty-four years of age. 
During labour the breech presented; and the transit of the 
foetus was so tardy, that Mr William Malloch, a very intelligent 
pupil, who had the management of the case, deemed it necessary 
to request the assistance of Dr Cochran, a neighbouring practi- 
tioner. After a good deal of active traction, a still-bom child 
was extracted. The head was much enlarged, greatly elongated, 
and so squeezed together, owing to the compression to which it 
was subjected while it was being dragged through the pelvis, as 
to resemble a tin kettle or canister which had been exposed to 
much pressure ; and although from its great expansion it was 
evident that it must have contained a considerable quantity of 
fluid, yet it seemed nearly empty. There was a spina bifida 
of considerable magnitude formed on the sacro-lumbar junction, 
which had been burst during labour, and through which the fluid 
contents of the cranium*, passing along the spinal canal, made its 
escape. Some years ago, in an infant affected with spina bifida, 
the pressure of the hand apphed to the tumour was observed to 
cause the young subject to become comatose ; and hence there 
was satisfactory evidence that a communication existed between 
the tumour and the brain. 

After the cranium in the foregoing case was distended to the 
volume which it possessed previously to the escape of its contents, 
it measured, by callipers, after being denuded of the soft parts, 
— ^from the chin to the anterior angle of the left parietal bone, 
6^ inches ; from the chin to the posterior angle of the same bone, 
at the extremity of the sagittal suture, 6^ inches ; from one pa- 
rietal protuberance to the other, 5| inches ; and in circumference, 
18| inches. Its parietes are, to a great extent, membranous ; 
the parietal bones much expanded ; the forehead projects, the 
face is siink in as it were, and is remarkably small compared 
to the size of the head. This foetus, contrary to the character 
of every production of this nature that I have hitherto seen, was 



OF CONOENITE HYDROCEPHALUS. 115 

yery fully developed. No reason has been assigned for the 
foBtus being diseased, except that, according to the statements of 
the mother, she has been subject to much vexation during gesta- 
tion, in consequence of the irregular habits of her husband : no 
hereditary disposition, as is strikingly manifest among the pro- 
geny of some families, could be traced. This is not the only 
instance of congenite hydrocephalus that I have seen, arising 
under the influence of protracted mental emotions and irregulari- 
ties on the part of females during gestation ; and I presume it 
must be familiar to the profession, that a diseased offspring is not 
unfrequently produced under such circumstances. ^ 

Edinburgh, 4 Picardy Place, 20th May 1844. 



Observations on Dr CamphdVa Paper on Congenite Syphilis, in 
the First Number of this Journal. By W. Acton, Esq., 
of Queen Anne Street, Cavendish Square, London. 

In my work on venereal diseases, I ventured to call in question 
the truth of several ancient dogmas held in great veneration by 
accoucheurs of the last century, and which I was inclined to 
believe were admitted on too slight grounds by some even in 
the year 1840. In the last number of the Northern Journal I 
find Dr Campbell somewhat indignant at my questioning these 
opinions, which he states ** men of experience, who have been 
engaged in pra>ctice half a century or more, maintain to be true.'' 
On this occasion I purpose stating the points of difference 
between Dr Campbell and myself. I believe that accoucheurs 
are in error in attributing solely to syphilis ihe occurrence of 
abortion about the seventh month, and my reasons are the fol- 
lowing : — 

1st, In the wards of hospitals devoted to venereal female 
patients, labouring under secondary symptoms, abortions are not 
more frequently observed at the seventh month than at any other 
period; 2dly, These females, in spite of all moral and physical 
impression, frequently carry their children to the full period ; and 
at the time of birth we meet with the in&nt quite healthy, or only 
sickening some weeks after. Such being the natural course of 
syphilis when observed on a large scale, I have hesitated in con- 
cluding that syphilis produces abortion at the seventh month, or 



11^ OBSERVATIONS ON DR CAMPBBLL's PAPER 

that the circtuostance oi a diild being boj*ii deadt)r putrid is of 
itsdf of any value in the diagnoMS. 

Dr Campbell, on the contrary, is an inij^iidit believer in tho 
opinion, that when women miscarry abolit the seventh month, and 
the child is putrid, we must look to syphilis as the caxfise, and 
that a 'cure will be effected by giving mercury to both parents : 
the t*eason he assigns for this belief is, hiving witne$»ed the oc- 
currence very fre<|uently ; and he gives the two folio wibg cases 
in support of his opinion :— 

A physician contracted ifhat he believed to be a chancre ; 
six months* after he married ; three children were successively 
prematurely born ; the first lived only a few hours ; the second 
' infant was born between the sixth and seventh month, and lived 
eight hours ; the third labour came on in the seventh month, 
the foetus dead and decomposed ; no trace of syphilis was ob- 
served in either parent ; the father and mother were salivated, 
and the next child was born vigorous and free from any syphi- 
litic taint. 

2d Co^e.^^-^Seventeen years previous to marriage, a gentleman 
suffered from syphilis, which he was assured was cured, although 
-an impresision remained on his part that the disease had not been 
completely removed ; both parents were apparently iA perfect 
health ; the first child was bom in the early part of the eighth 
ihonth of gestation, was delicate, and lived eleven days ; the 
iseccmd birth haj^ened in the seventh month, the infant survived 
only an hour and a half; the third delivery occurred in the dxth 
month, when a foetus much decomposed was produced; the 
husband and wife were salivated, and a living healthy small 
female foet^is was born at the close of the eighth month. — Having 
related these two cases, Dr Campbell criticizes my opinions^ and 
«tates» 1st, That information derived from venereal hospitals is, 
to say the least, questionable ; 2d, That my field for observaitibn 
was far too limited, considering that, on an average, not morfe 
than sil prostitutes in one thousand conceived in the course of 
one year, according to the investigations of Duchatelet ; and, 3d, 
That <^inions based on such dati cannot be put in competition 
with the experience of men who have be«i half a bentury or 
more engaged in practice. 

The reader inust observe^ that if Dr Campbell admits syphilis 
as the cause of abortion in the above-cited cases, he will be 
obliged to believe that two parents, neither of whom have had 
secondary symptoms, but enjoy excellent health, will prodtioe 



ON CONOBNITE «YPHILIfi. 117 

not syphilitic childr^i in the sense usually understood by authors, 
but infants that present no recognised syphilitic symptom^ ualeas 
preiliature confinement or d. putrid foetus be consider^ as such ; 
thus excluding all other causes of abortion, and reoogniaing as 
the cause a chancre without any of its attendant seiqUelfle. 

In the second case, he must believe that chancre, unattended 
by secondary symptoms, will, after seyenteeti years^ show itself 
in the child, not in the ordinary forms, but in that whkh eaO- 
coucheurs affirm is syphilis, consisting in the death <^ the foetus 
and pr^nature confinement. This doctrine will> I thiuk^ be at 
once denied by all practitioners who have idlowed th^ patients 
to marry, and obserred the healthy oSispriDg of those who in 
early life contracted chancres not followed by aeeondary syn^ 
toms. In reply to Dr Campbell's first objection to my opinions, 
I must repeat, that a large number of pregnaiit womeu ^^re 
nnder my care at the yenereal hospitals in Paris, but that / did 
not observe this liability to abortion during the seventh month. 

Dr Campbell's statement, on the authority of Duchatelet, that 
only six prostitutes in a thousand conceived in the course of one 
year, appeared so much at variance with what I had witnessed, 
that I rkerred to his book, and find, as I expected, that Dr 
Campbell has completely misunderstood the French author, who, 
at the commencement of the chapter (De la F^ndit^ chez les 
Prostitu^), says, '* En resumant toutes les r^ponses qui m'ont 
^t6 faites, et ce que j'ai trouv^ dans qudqties livres anciens et 
modemes, j'ai du tirer cette conclusion, que mille prosiitui^ 
foumissent k peine six accouchemente/^ dans la courant d'une 
annde ;" which I should translate as follows : " Judging from thte 
answers I have received, and what I have found in soTne ancient 
and modem works, I ought to draw this conclusion, that a thou- 
sand prostitutes scarcely furnish six aceatichements during the 
course of the year." He, however, in the next line goes oh to 
say that, not satisfied with these data, he made further personal 
investigations ; and at page 233 he gives a table to show that the 
acconchements which take place in the hospitals are on an average 
51^, and a few lines farther on he augments it to 63^ ; at page 
241 he adds, '' tout semble done prouver que les prostitu^ sont 
plus aptes k la ft^ndation qu'on no Ta era jusqu^itei." I hop^, 
then, Dr Campbell will uow give me credit for having observed 

* I have marked the word aecouehemenU in the text, as weU as quglquet, and 
condade that Dr CampbeU is weU aware that the French word is not rendered into 
English by conceived. 



118 OBSERVATIONS ON SR CAMPBELL'S PAPER 

on a larger scale than this misquotation would lead his readers 
to suppose.* 

If I understand Dr Campbell's third objection to my opinion, 
it is, that none of his juniors ought to dispute his opinion unless 
he can back it with the experience of half a century. With all 
deference to the doctor's years, I must, however, remind him that, 
in these sceptical days, a host of things (the truth of which was 
formerly never doubted) are now held in disbeUef ; that a stem 
array of facts and figures, with strict observation of the ordinary 
course of disease, is now required to defend an old doctrine or 
support a new opinion; and that the heads of the profession 
must condescend, like their juniors, to employ these means, and 
not only count their facts and opinions, but weigh them. 

46^ Queen Anke Street, Cavekdish Square, 
London, May 1844. 

NOTE BY THE EDITORS. 

Though we are determined, as far as possible, to prevent this 
Journal from becoming a field for acrimonious personal contro- 
versy, we are equally resolved that no one shall have just cause 
to think himself aggrieved by our articles, or those of our con- 
tributors, without having ample opportunity of setting himself 
right with our readers. We have therefore published Dr 
Acton's answer to some passages in Dr Campbell's paper, in our 
first number, on Congenite Syphilis. We observe that Dr Camp- 
bell did expressly refer to Dr Acton as one of those who maan- 
tained the opinions against which his paper was directed ; yet 
in doing so, we consider Dr Campbell as having paid a compli- 
ment to Dr Acton's recent work, since that was singled out as 
one of the works of reputation in which such opinions were 
entertained. And we remark nothing in Dr C.'s article, in 
reference to Dr Acton, which can make us regret its having 
obtained our imprimatur without erasure; neither do we 
discover in Dr Acton's answer any deviation from that gentle- 
manlike style in which scientific controversy should be carried 
on between one member of a liberal profession and another. 

On the present occasion we have no intention of becoming 
partisans either of the one opinion or of the other ; but since our 

* See Note by the Editon. 



ON CONGBNITE SYPHILIS. 119 

two contributors are at yariance in regard to the support af- 
forded by a particular work to their respective sentiments, we 
have deemed it our duty to consult that work. If any one will 
take the trouble to read the whole chapter in Duchatelet's 
work, "De la F^condit^ chez les Prostitutes," concerning 
which these two gentlemen are at variance, and certain passages 
of which each somewhat hastily interprets in accordance with 
his own views, it will be found that the purpose of it is to show 
that prostitutes fail to add to the population, not because they 
do not conceive often, but because, after conception, abortions are 
frequent at all periods of gestation, and that, when carried to 
the period of viability, the infants almost uniformly die. So 
iiELr Duchatelet's statement is favourable to Dr Campbell's 
object. But it is plain that the passage which Dr Campbell 
cites from Duchatelet does not comprise his final opinion on the 
subject of the proportion of deliveries in a given number of 
prostitutes, but only that which the evidence first considered 
should have led him to adopt, and that he goes on to extract 
from various additional documents a new conclusion, — ^not, as 
Dr Acton seems to state in the above reply, at the rate of 51^ and 
63^ deliveries for every 1000 prostitutes, but at that rate annu- 
ally on the whole number of prostitutes in Paris ; or his final conclu- 
sion is, that, taking the returns for 1832, there being from eight 
to ten annual deliveries not included in the above rate, there 
were in all 76 deliveries, or 21 in every 1000 of this part of the 
population. We here correct a material error in this chapter — 
57 being put for 75 — the only figure, it is plain, which, out of 
3558, the estimated number of prostitutes in 1832, will give 21 
in the 1000. The whole chapter, indeed, is perplexing. With 
the following quotation, which gives the substance of Duchatelet's 
views on this subject, we leave our two friends to debate the rest of 
the question, as they seem inclined to do, in an amicable manner. 
" Tout semble done prouver que les prostituees sent plus aptes 
k la fecondation qu'on ne Pa cru jusqu'ici ; qu'il faut, pour cette 
fecondation ait lieu, une reunion de circonstances et, pour ainsi 
dire, le concours de la volonte et du laisser aller de la fiUe, 
veritable etat intellectuel et moral etranger a I'exercise habituel 
de son metier ; que si les filles publiques amfenent rarement leur 
grossesse au terme ordinaire, c'est qu'elles avortent presque ton- 
jours, soit que ces avortements aient lieu par des manceuvres crim- 
melles, soit qu'il faille les attribuer k I'exercise de leur mdtier."* 

* Parent Duchatelet, i. 241. 



120 POISONING BT THE LEAVES OF ACONITE. 

Case o/JDecUh by Pois&ning with the Leaivea of Aconite or Monh^ 
hooiij passed off in Jest for Parsley. By Alex. Ramsay, 
Sui^eoB, Broughty Ferry. Communicated by Db Webster, 
Physieian to the Royal Infirmary, Dundee. 

On Friday the 19th April 1844, I receired a message to ex- 
amine the body of Hanton, aged fourteen years, who 

had died suddenly during the afternoon. On inquiry I ascer- 
tained that, on passing a garden in the parish of Murroes, about 
11 A.M., he looked oy^ the wall and asked a young man in 
the garden '*if he would giYO him some parsley ;" to which it 
was answered, that he would get some new parsley, which was 
much better than the .old kind. The young man accordingly 
gaYe Hanton a handful of green leaYCS, of which he ate some. 
When Mrs Hanton returned to dinner from her field lal)our, 
she found her son complaining of burning sensation in the 
lOQiith, throat, and stomach, and Ycry sidk. About one o'clock 
his mother gaYe him a glass of whisky, thinking that this *^ cure 
for eYcry ill" would relicYe these symptoms. After getting the 
whisky he went to bed. His mother, thinking he would be well 
in a few minutes, left him alone in the house, and went to her 
work. Shortly after this, Hanton got up and went to a black- 
smith's shop across the road, where he took a fit and fell on the 
ground. This at the tim^ caused no alarm, as the boy smelt of 
whisky, and it was belioYed he was intoxicated. On his re- 
coYcring he found his way back to the house ; and at six p. m., 
when his mother returned from her work, she found him lying 
across the bed, with his hands in his pockets, dead and stiffening. 
The floor of the room was wet with fluid, which he had ap- 
parently Yomited. While in the house I was shown some of the 
leaYCs of the plant from which the boy had eaten, which seemed 
to be the aconitum neomontanum.* I gaYe no decided opinion as 
to the caii3e of death, but, in order to allay all surmisings and 
suppositiims, recommended that the body should be opened for 
examination next day, to which the friends agreed ; and I re- 
quested the kindness of Dr Webster of Dundee to assist me in 
the examination. 
The following are the appearances on dissection twenty hours 

• We have not yet been able to ascertain on what authority the plant was pro- 
nounced to be the aconitum neomontanum, which is a variety of the acanitum 
commarum of Lixrasus. — Ehjtobs. 



POISONING BT THE LSATBS O^F ACONITE. fiHJ 

after death. Externallj, the body was plump, and indicated the 
preyious enjoyment of health ; the countenance was pale, and 
sugillation had commenced posteriorly. On laying back the 
integuments oyer the oranhiiD> there was slight ecchymoeds over 
the occipital ridge, as if from a blow (which might hare been 
caused by the fall in the SHB^h's shop) ; and on remoying the cal- 
yarium, the whole blood-yessels within the head were found 
enormdusly distend^ yrith dark-colcmred fluid blood, upwardti^ 
of a poimd of which escaped from the i^uU and spinal tmtkl. 
The braiii was of natural consistence, but the y^entriekfi^ e&a- 
tadaed a consid&rable^ qus^ettky cf serum. The hmg» were 
healthy and not congested ; the heart also was normal, but con- 
taiaed no Mood. The stomach was oompletely empty, with a 
deep inflammatory blush oyer its whole internal surface, and 
here and there patches of a darker colour. We were not al- 
lowed to carry the dissection farther. None of the fluid ejected 
iva» pfeserred. Spechnens of the plant were, prior to this iisne, 
to be found in e^evy garden in the neighboarfaeod ; but such ^M- 
the anxiety to haye it remoyed out of sight, i^t it irould now 
be c^cult to procure a plant for ornament or use. 

It i» impossible te ascertain the esact quantity of the lMte» 
eaten in this case ; but i^e probalnfity is that, mistaken for 
parsley, ft was considerable. His death appears to have been 
caused by the apoplectic staite of the brain, probaMy endkig in- 
asphyxia. The administration of the whisky was most injudicious, 
and taided without doubt to accelerate the fatal event. Pro- 
haMy, had Ueeding been resorted to early aiod freely, the result^ 
might haye been different. Be this as it may, the case fdly bears- 
(^ot the remarks of former writers as to the highly dang^roffil' 
nature ef the aconite. I am aware that at this moment it is 
exdtiBg considerable attention as a remecKal agent in rheumatic 
aad neun^e affections, and I doubt not, when ju^ciously ad- 
diinidtered, it may proye a useful and powerful remedy. But 
a ^ug of such power wiU require yery great eare in administra-' 
tion, an^ rnxnute obseryaition of ite effects, before it can wMb 
safety be recosunended to incEseriminate adoption in general 
practice. I may remark, tl^t the plant itself oould not welt be 
mistake^ for parsley ; but that the deeply cut leaves, after being 
detached firem the stem, moght mislead tiie inexperienced. 
Moreoyer, it is some minutes after chewing it b€<9r^ ife bumingf 
tendency BHOHfests itself. 

Q 



122 DISEASES OF THE SKIN. 



Part IL— REVIEWS. 



A Practical and Theoretical Treatise en the Diagnosis, Patho^ 
logy, and Treatment of Diseases of the Skin; arranged 
according to a Natural System of Clasdfication, and preceded 
by an Outline of the Anatomy and Physiology of the Skin, 
By Erasmus Wiuson, Consulting Surgeon to the St Pancras 
Infirmary, London, &c. 8vo, pp. 440. London, 1842, 
Churchill. 

It is remarked by Dr Latham, that one reason why surgery is 
more popular than medicine is its being easier ; and he farther 
explains his meaning by showing that this comparative easiness 
depends on our abiUty to examine directly the diseases which it 
embraces. If this be true, of all the diseases which £sdl under 
the notice of the physician, those of the skin ought to be at once 
the easiest and the greatest favourites. There are none per- 
haps more easily recognised, none more frequently manifested, 
none more annoying to the patient, none which, if successfully 
treated, confer greater credit on the physician. And yet, are 
not too many of them the opprobria of medicine? Are they 
taught in general in our systematic courses ? Are they watched, 
as they should be, by the students in our hospitals ? Is the treat- 
ment of the vast majority of them founded on any thing better 
than empiricism ? And yet these diseases have been studied ; 
successful attempts have been made to systematize them ; the 
classification of Willan is stiU held up as one of the most won- 
derful examples of method applied to medicine. We have our 
tables constructed, our classes, our orders, our genera, our 
species, with all their essential characters regularly and determin- 
edly settled ; can any thing be more beautiful or more useful ? 
It may be heresy ; but we cannot help thinking that this classi- 
fica;tion has done much to retard the progress of that branch of 
pathology. It has bound and fettered the advance of know- 
ledge by conventional forms ; it has supplied us with systems, 
instead of facts ; it has abstracted, without generalizing ; it has 
presented us with the form of knowledge, without the reaUty ; 



DISEASES OF THE SKIN. 123 

it has pretended simplicity, where it has created confusion. We 
are therefore prepared to welcome any work which proposes to 
break through these trammels, to destroy these unnatural dis- 
tinctions, and to present us with a lucid arrangement, or, better 
still, with a lucid description without any arrangement, of the 
multifarious diseases to which the skin is subject. Mr Wilson 
proposes to himself the former of these tasks. Comparing the 
system of Willan to the Linnssan system of botany, he comes 
forward, the Jussieu of dermatology. In his own words — 

^ The thought occurred to me that the study of the diseases of the skm 
might be much simplified, and consequently facilitated, by the creation of 
a system which should embrace all the adyantages offered by the natural 
system, while it retai^ed the benefits derivable from the artificial system. 
It was this thought that gave origin to the system which I have endea- 
Youred to illustrate in the following pages, and for which I have assumed the 
appellation of— Natural System of Diseases of the Skin." (Pre&ce, p. 9.) 

Our author seems to have imagined that he was the first to 
premise an accurate history of the organization of the skin to 
the study of its diseases, which, however, is not the case. The 
work of Lorry (Tractatus de Morbis Cutaneis, Parisiis, 1777) 
goes very minutely into the nature and structure of the skin, 
and these very necessary inquiries have imparted a spirit and a 
character to that work which raise it to a high place among 
treatises on this subject. To Mr Wilson, however, certainly 
belongs the merit of first resting a classification on the basis of 
anatomy and physiology, and if the study of these diseases is 
really to be promoted by such means, we must award to our 
author the title of a reformer ; which, in many respects, he de- 
serves as certainly as he has ambitiously claimed it for himself 
in his somewhat affected preface. We are not sure that the 
classification of Mr Wilson will find even the favour which it 
deserves. Scientific men are not now so eager to systematize as 
they were half a century ago ; disliking also new names for old 
thmgs, they will rather start at being told that ephelis is a " dis- 
order of the chromatogenous function," and will perhaps under- 
estimate the utility of calling a pustule a " suppurative inflam- 
mation of the dermis."* Some of our brethren also, who, to 
borrow an expression of Sir Astley Cooper's, " exhibit the snow 

* The word <' dermis " occurs repeatedlj in this boolc We woDder that a scholar 
like Mr Wilson should employ it ; we have long known it as a sort of coekneyism 
of the London schools ; but we thought it had been confined to the slang of the 
dissecting room. There is assuredly no such word in the technology of anatomical 
sdenoe. 



IM J>I$SAI&E^ OF THE SKIN. 

QB, the topi ^q{ ibe mouBtfu^/' will perbapft eio^oflaiii of the 
doffw^ism with wbioh JMbr Wikoa m»intftiTm o^vt$w apiiuoDB 
reiQkoned hfareticaly and may be inioliiied to d^v^eaxd. proof for 
Siom^ of Jiift assertions. For example^ whw he mforma us th^^ 
.seabjj^s is iKyu<iri<jMy produced by ih» iifik^iiOAQCij i|t is not s«ffir 
dent .to add, ''there is no part of th^ pathology of cutaaeoua 
disacuiea^ of the truth of w^oh I feei bdtt^r satisfied* th^^ of 
this.;" and mstead of eensuring M. GriBL^ for stopiHng Bhort 
when-fsfits eeasi^d to snppoFt him, and^ 9^ Mr Wilson ee^jM^es^es 
it^ *' faltering when aboiit to oonchide ibe race/' it WAidd have 
I^een better bad hd hin^elf ejc^iieised a simils^ cauti^n^ It is 
imahe tells ns, '' I am thovougbly Gooviaced, aad m long aa I 
possess fhut conviction shall erer continne to mgintaiH, that 
acarup is the sole and oidy cause of scalnes/' This is all right; 
b]«it we ^ugbt surely to have been told on wbat^ tb^se decided 
convictions rest. We have no prepossession either way, and 
might possibly be convinced by the same reasonixig which has 
made our author so decided, provided only it were furnished to 
us. But, after all, this dispute, like many others, is chiefly about 
words, for Mr W. goes on to say, that " every eruption, how- 
ever acuminated and well de&md its vesicles, if it be deficient 
of the living cause, is not scabies." (Preface, p. xvi.) This is 
of course just assuming what he was required to prove; for if 
Mr W. is determined to exclude from itch all those cases ip 
which the acarus is absent, no matter how characteristic may be 
the eruption, it would be of course absurd to argue with hijn 
that the insect is not present in every case. But he ought cer- 
tainly to have given us a name for those cases which w^ should 
be thus obliged to exclude. Another instance of the same posi- 
tive assertion, " unsubstantiated by any proof," occurs in refereiwe 
to the eruptive fevers, which our aulior believes '* are diseases 
r originating in the same morbid contagion, the differences between 
them depending on modification, either of the physical or of the 
vital conditions of the system by whixjh the contagion is received." 
(Preface, p. 13.) 

But we have really no wish to quarrel with a book presenting 
so maQy excellencies ; and if Mr Wilson has failed to add any 
thing very novel to our knowledge of cut;3,fieous diseases, he has 
tixe high merit of simplifying that knowledge, and of having 
ooUected into a very degant volume the most valuable facts 
which the science presents. 

The diseases are divided into four classes, according as they 



PiaSAS^S O^ THJe SKiN. 1J26 

9Beeb the dpn, tibe /»udoripi^oi}a ^ndsi ^ i^bMeowi i^^ei^ 
or the hsm md bair'^folli^lea ; i^d the ftrst «hlt]^r ioAroduQ^ 
ns to the miatomy aad physiology of th^e p^krtft. .!« ti^ 
<^pt«r, Mr Wilson appears to adyaipiitag^. :He ia ^id^% ^ja 
aecmiplished and sciantific anatomist* and th^ jnmi^ »t}«^ cif 
the tissues appears to have engaged much of ]m i^Atioiv Ia 
bis dc^ription pf tbe akin and epideriQis, w^ do not find much 
th^tis ftovel. Thd mode of reprodfictioin and growtb of Ib^ 
latl^ is amply mi briefly explained. J.hie pigi&i9Pt q{ the 
jikin, the sudoriparous a^d sebaceous glanda» and the filmmiii 
e<»Qpo»tioQ (rf th^ir aeeretions, are ably and fi«Qpii»^y d04«ntt>ed. 
In (bussing the subjeot of perapko^tion, the skvi^r 9iMm to 
ito impiQ^rtainoe in health, and eite^ the e^p€flfkn^i# of MM. 
Foiarcattlt, Beoqu^rel and Breschet, of which be give* ^M- 
lowmg account : — 

^ Tb» i^eent ai^erimento of M. Fonreault* thvov 09i«i^ei)shto IjigM on 
the jmpoTtWioe ito hoolUi of the seereting fonetjon of "the idcb. The T^ 
«ilt»of t^e obwxv^atioQS made by this g^nUesumgo to abow, thAl^ if th^ 
cataneous transpiration of an animal be wbolly j^ir^vented by fxk^fijfm of an 
impermeable covering, the animal will die in a short space of time, appar- 
^tly in a state of asphyxia. Becquerel and Breeohet, pursuing tJieir 
expenments on animal temperature, conoeived, that if tbey e<mld piw^^mt 
truispimtion by the skin, they should induce internal fever ; the contraij, 
however, was the fact. After the application of a thick layer of vamisn 
upon the skin of a rabbit, and adjusting their thermo-electric needles, they 
found the temperature of the deep musdes^ in the course of ha}f an houf, 
to be reduced from 38 to 32 ; in another haLf-hour, to^^*^ ; and i^ a thii)d 
half-hour, it stood at only 3 degrees above the temperatuore of the atmo> 
sphere, 17 ; so that, in the course of an hour and a half, the temperature of 
the animal had &llen eighteen degrees, and the creature died.*' P. 19. 

The second chapter is devoted tp the consideration of tho.se 
diseases to ^hich the name of congestive inflammation of the 
dermis. is give^. These are divided into those with and tho^e 
without specific constitutional symptoms. The former compre- 
hend the eruptive fevers, the latter, erysipelas, urticaria, roseola, 
erythema. We shall not notice here the eruptive fevers, but ^t 
once pass on to those diseases which are really entitled to be re- 
garded as affections of the skin. We are obliged to quarrel with 
Mr W„ at the very outset of his excellent article on erysipelas, 
for a fault of the same character as that which we have already 
reprehended. In the definition of the disease, the fever is cba- 
rapterized as " contagious and infectious.'* We have no wish 

" ^i ji, ■ ^ Ji J » > ■ 1 u . ■ !■ - ■ ■■■ ■ . ........ — r.j . ■ * • I 

* £;i;^|]|iaAteur M^dicAle^ QcU 1841, 



126 DISEASES OF THE SKIN. 

to discuss this disputed question — few are inclined now, we be- 
lieve, to agree with Mr Wilson — nor are we disposed to attach 
much importance to the experiment of Williams or the case of 
Costallat, but would only inquire. Is the infectious and contagious 
nature of the fever sufficiently established to make it the ground- 
work of a definition ? 

The treatment of erysipelas is ably discussed. The mind of 
our author is of too philosophical a character to allow him to 
become the advocate of any exclusive system ; and, while he 
admits the applicability in certain cases of the stimulant plan of 
treatment, so confidently recommended by Williams for all cases, 
he does not deny the necessity of resorting to blood-letting when 
the state of the circulatory system warrants its employment. The 
indiscriminate advisers of antiphlogistic treatment would do well 
to consider the following excellent caution : — 

*^ Under all circumstances, it must be borne in mind that ery^pelas is a 
disease of reduced powers, and, consequently, so soon as the artificial ex- 
citement produced by the fever shall have passed away, our eflPorts must be 
directed to the restoration of the tone of the system." 

Mr Listen has drawn our attention to the &ct, that the symp- 
toms of increased vascular action may arise from constitutional 
irritation ; and thus, instead of being ameliorated, may be in- 
creased by venesection. With regard to local treatment, eva- 
porating lotions, warm fomentations, or water-dressing — ^the tem- 
perature to be determined by the feelings of the patient — are 
recommended. We wish our author had placed some limitations 
on this treatment, for we cannot help concurring in the opinion 
of Mr listen, that the *' use of spirituous and evaporating lotions 
is fraught with the utmost danger ; for their direct tendency is 
to produce metastasis, and if that be to an internal organ of im- 
portance, the result is too generally fatal." The treatment, so 
fashionable at present, of mercurial inunction, is not alluded to ; 
and we think the experiments of Rayer fully justify its being 
discarded as a remedial means, though we are in the habit of 
keeping the affected part smeared with hog*s lard, from the 
relief which its application appears to afford to the patient. 
Puncture is recommended where there is much congestion of the 
vessels of the skin, and incisions where there is deep-seated sup- 
puration. This, we think, is dealing properly with the disputed 
question of puncture or incision. It has always appeared to us 
that these were resorted to for different objects ; the one, — ^punc- 
ture, serving to relieve vascular congestion, or even, from the 



DISEASES or THE SKIN. 127 

free intercommunication between the cells of the ceUular mem« 
brane, to give escape to acoumalations of fluid ; the other, inci- 
sion, being imperatiyely demanded whereyer there are deep- 
seated accumulations of pus, or sloughing of the cellular tissue. 
The actual condition of the parts must in every case be our guide. 
We are glad'to observe that Mr Wilson follows Mr Listen in 
recommending the extracts of aconite and belladonna in this affec- 
tion. We have seen great abatement of the febrile symptoms, with 
manifest reUef to the local uneasiness, follow their employment. 

The remaining diseases in this class need not detain us 
long. We regret that Mr Wilson has not included in his 
description of erythema that singular epidemic variety of it 
which occurred in Paris in 1828, and to which the name of 
acrodinia was given. We were a little startled with one of the 
remedies recommended for the treatment of erythema, — ^the 
friction of the skin with croton-oil liniment. We have been 
accustomed to regard the pustular affections of the skin as usually 
more severe than the slighter exanthemata, and, to apply to the 
vocabulary of Mr Wilson, would be loath to engraft a suppura- 
tive upon a congestive inflammation of the dermis. 

The fourth chapter of Mr Wilson's book is devoted to the 
consideration of those inflammations of the skin which are cha- 
racterized by effusion of a serous fluid upon its surface, and em- 
braces the orders Bullae and Vesiculsd of Willan. This group is 
still further dividedinto sthenic and asthenic, theformer embracing 
the bullous, the latter the vesicular diseases. We are not disposed 
to acquiesce altogether in this arrangement. The separation be- 
tween bullous and vesicular diseases is certainly unnatural ; and we 
also doubt very much whether we are warranted in regarding 
all the cases where blebs occur as asthenic. The disease — acute 
pemphigus for example — though rare, is certainly attended 
with fever of the sthenic type. Nor does it, like the other 
varieties of the same disease, usually occur in individuals of a 
broken-down constitution. 

Our author properly follows Rayer in classing pemphigus 
and pompholyx together, and placing rupia beside them ; from 
which natural position Willan had removed it, forcing it into the 
class of vesiculad. He removes the miliary eruptions from ihe 
vesicular diseases, placmg them under disorders of the sudori- 
parous system. Hydrargyria he considers identical with 
eczema, except in its cause ; and scabies is placed in a class b j 
itself, as a disease invariably produced by parasitic animalcules. 



Wd do not tlndt there its tfiUcb of novelty in the i^effiedies 6( 
Mr Wflson in these &easeE^ We are sufpi^sed ^th the 
rii^i notice tr hicb that setere and dangerous affection receives, 
to which the name of rupia escharotica or pemphigns gangrsen^ 
oisus has heen given. It is tr ne thia dkease seems indigenous to 
Iceland only ; and by far the best description which we have' of 
it is by Dr Stok^ senior. (Dnb. Med. and Phys. Essays, vol. i.) 
Thi^paper, however, seems^to have escaped thenotice of Mr Wilson, 
as ttolhing is said by Mm of the scroftdaria ointment, which Dr 
Stokes found so nseftd. tJnder the same head, we think, might 
be included the fatal sloughing of the pudendum described by 
Mr Kindw Wood of Manchester. In this chapter a foot-note 
informs us^ that M. Gmby, whose researches we shaH have 
aecasiGHQ to speak of in connexion with favus, has discovered a 
plant in the bulIsB <rf nq)ia. We observe from a recent report 
ot the French Academy of Sciences, that the same distinguished 
observer has found (O^yptogamous vegetations in the variety c^ 
herpes, termed " tonsurans " by M. Cazenave. 

In reference to sudamina, Mr Wilson adopts the decided 
opinion of Batemsm, that tbey invariably proceed from the effect 
of a stimulating regimen and a confined atmosphere. We suspect 
this is extreme, and ^ould be inclined rather to coin<Me with 
the views of Professor Schoenlein, which he thus expresses in a 
lectore recently pubUshed : — 

*^ i have also to observe, that the eraption of miliaria frequently takes 
place in spite of a cooling antiphlogistic treatment, as I have more than once 
seen at Wurzbnrg, where it often appeared on the second day of the complaint, 
in iqpfte of blood-letttng. The physiciaiis in Verona and Bergsano have made 
the same remaife. The i^pearance of miliaria must therefore not be made 
an immediate subject of reproach to the physician, for, by in<^uiring at those 
places where miliaria has epidemically reigned with fatal effect, we find 
that the exanthema appears in spite of all medical care. If a physician finds 
no eraption of miliaria in the place where he practises, he should be thank- 
ful for ity and not forge weapons on that account against his colleagues. 
Nor can we be reproached with having violently suppressed the diarrhoea^ 
and having thereby called forth the miliaria." — Lancet^ iVb. 7. 

In the fifth cha|)ter of Mr Wilson's book, undier the ikh 
" Suppurative Inflammation of the Dermis,*' are comprehendcid 
i^ pUBttlar diseases, which are restricted t0 impetigo and 
ecthyma^ Oar auibor very ptoperly follows the French school 
in adbolisUng the genus porrigo, and transfers variola to th4' 
eruptive fisversl Favus i» regarded as a disease of the hair* 



DISEASES OF THE SKIN. 129 

follicles, and sycosis as an inflammation of the sebaceous glands. 
There does not appeal* much that is novel in these chapters. 
In the treatment of that exceedingly troublesome aflfection 
"impetigo of the scalp/' the absolute necessity of cleanliness is 
strongly enforced; and the following incident, which, as the 
author says, '' speaks volumes with regard to the treatment of 
this disease,*' is recounted : — 

^ I had often occanon to obserre with regret the utter useleaEnest of all 
medicinal applications in the treatment of these cases in the St Pancras In- 
fiimary, where numerous children are annually affected, and several are 
constantly in the sick wards. This want of success originated in the absence 
of proper nurses to carry out the directions of the suigeon. It was in vain 
that the necessity of cleanliness was urged upon them ; they received little 
for their labours, and were not disposed to engage in a most disagreeable 
duty on philantlux>pic grounds alone. Under such circumstances, the phar- 
macopoeia was exhausted of its specifics^ but no advantages resulted. Things 
were in this state, and I had little hope of change, when, to my surprise 
and delight, I perceived the number of patients suddenly diniinish, and 
those who remained looked cheerful and better in health. I inquired into 
the cause of this change, when I learned that a new nurse had been appointed 
to the charge of the children, and that she had set her shoulder vigorously 
to the wheel of these obstinate eruptions, and had turned out sevend cures. 
Upon asking her how she proceeded, she of course looked mysterioufl^ but 
I quieted her fears of my perquisitions, by telling her that it was not her 
secret that I sought, that my object was simply to approve of her proceed- 
ing, and to urge her to its continuance. She said in reply, that her treat- 
ment consisted in the application of a remedy derived from a 'subscription' 
giren to her mother by Sir Astley Cooper ; that this legendary specific was 
a coarse admixture of ' butter and pepper.' For sound philosophy this 
remedy,* in its modus operandi, is worthy of the celebrated name with 
which the female Asclepiad had associated it, and I applauded its effects ; 
it was an apt illustration of the sympathetic treatment of wounds by 
aaomting the wei^n with salves, and swathing it in countless bandages. 
Bat I reserved for myself that which my female oolabonrer could not have 
oomprehended — ^the perception of the benefit derivable firom the thorough 
ablaticMis and rigid deanliness with which the specific was acoompaniedL'' 
P. 187. 

Chapter sixth, under the title of " Depositive Inflammation 
of the Dermis/' discusses the order papuIsB of Willan, which is 
strictly adhered to ; even Ray er's improvement of oniting stroph- 
olns and lichen is not adopted. Mr Wilson believes that 
pimples consist essentiall j in an effnsion of plastic lymph into the 
tissue of one or more of the papillae of the dermis. There is 
nothing in this chapter that need detain us. 

In the treatment of the obstinate class of sqaamons diseases, 

* '^ A hamhle'mutalkm oi ilMtungaeDtmkm^ 
ftmcdy leeonmaMlcd ftr fimis**' 



190 DISEASES 07 THE SKIN. 

to the consideration of which the following chapter is deroted, 
we find some valuable remarks. I^nce M. Biett directed at- 
tention to the employment of arsenic and tincture of cantharides 
in these affections, the j have perhaps been too g^erally resorted 
to ; and it is well that those who use them indiseriminatel j should 
remember the caution of Rayer, which is quoted by Mr Wilson. 

** ' It is undeniable that by means of these active medicines several of the 
varieties of psoriasis^ even the most inretemte, have beea eared ; Imt it is 
no less certain, that the maj<Hity of the om«8 tiuis aooMiq»lithed have been 
but temponay, relapses having oceiuved the foUowii^ ^xing er aoitnmn; 
that such relapses are more especially frequoit among the labouring cbMOi 
of the community ; and, lastly, that the greater numb<» of eases of paon^sii 
inveterata treated by such means have been in nowise amendiM^ akhoug^ 
the medicines were contbiued for five or six mentlM. I am therefeie of 
Opinion, that it is, in genersl, inexpedient to put patients affected with 
psoriasis inveterata upon an arsenical course, in the &int hope of deriving 
a mere temporary improvement, with the §Ux before our eyes of inducnag 
some obstinate derangements of the digestive oigans^ or of permanently in- 
Jurmg tile general constitution.* ** P. 290. 

Among the local applications recommended in these affections* 
we find three remedies which we have not brfore seen noticed 
by any British author. Anthrakokali is a chemical compound 
of potass and coal, and was introduced by Dr Polya of Pesth, 
who gave it internally. Gibert found it fail as an internal 
remedy, but succeed well externally as a mild stimulant applica* 
jtion ; but he is inclined to prefer the fuligokali, a compound of 
soot and potass, prepared in imitation of antfarak(^ali by M. 
Deschamps. The following is Mr Wilson's account of the pre- 
paration of this remedy : — 

'^ As an external application, in the form of ointment^ ft is re0oli:^ive^ deterw 
sive, and stimulant. The mode of prepamtion of the compound is the follow- 
ing: — ft Caustic potass, 20 parts; soot,100part8; water, q. 8. Boil the mixture 
for an hoar ; cool, filter, evaporate, and dry. The fuligokali is obtained in 
the form of scales or powder, and must be kept in well-stoppered bottles in 
a dry place. A sulphuretted fuligokali is obtained by the following pro- 
cess : — ft Soot, 60 parts ; caustic potass, 14 parts ; sulphur, 4 parts. Heat 
the sulphur and potass with a little water, and after their sokitMm, add the 
soot. Ev^orate, dry, and dose the resulting compound in wellnrtoppered 
JMtles, and keep it in a dry place. The ointment used by M. Gibert is 
composed of a scruple to half a drachm of the salt to an ounce of lard. In 
larger proportion it is highly irritating.** P. 396. 

We are also informed that 

^ M. Lemery, of Saint Louis, has lately recalled the attention of practi- 
tfoners to an old but valuable application in lepiooa afieetioD8*^na]nely, 
tor. Fmding, however, that this remedy was objeetlttiaMiis on aooouiit of 



DISSASES OV THS SKIN. 131 

its eoiofarwid odour, ho liod ifooimo to one of the picdncU of far, 9omenU 
mapkihaSney which afibided him the moot saoceflsfiil lesolts. The piepcn- 
tioQ ndiich he employs is an ointment^ composed of naphthaline^ two to four 
parte ; laid, tluitf pasta. This he applies to the disnsed sIob, on iolda of 
ImeD, B^^ and morning. The ointment is highly ttimwlating^ v*^ hw a 
powofol ameO, idiieh qoickly passes away. By means of the ni^hthaline 
ointment. If. Lemery succeeded in caring e^ht patients out of fourteen, in 
frran fire weeks to three months." P. 221. 

We are nirpriaed that an author ao Tersant as Mr Wilaon 
m medkal fiterature, tuuimst as well as modern^ should not have 
noticed, in oonnexion with the treatment of sqnamoas diseases, 
a remedy introduced by Dr Burgess, with which we hare sac* 
eeeded in improving sereral yerj unpromising cases. The 
aflhcted part is exposed to the Tapoor produced by throwing the 
following powder on a hot iron : — 'Bt Snlphnris, SiiL ; hyd. sulplu 
mb. ^iL ; iodinii,gr. x. The limb maybe continued in the both 
team fif te en to twenty nmrates* In the oourse of a day or two 
the proportion of iodhie may be increased (Burgess' Translation 
efGaBenaTe,p. 209). 

In some obstinate cases we haye found the following lotion of 
lerrioe: — ^& Greosoti, gtt.xx; ac hydrocyan« med« 3i; aq«r 
fontis, 3zii. : M. ft. lotio. 

Chapter dghth discusses inflammation of flie cutis, induced 
by parasitic animalcules inhabitbo^ the epidermis, which eompre-i 
heads scabies alone. We had intended to dispute with Mr 
Wilson the propriety of this exduaye view of this subject, bul 
fasTo already exceeded our limits so much that we must not at* 
tempi it. Those who beheye the disease to be produced ezclu« 
BTcfy hj the aearus, will be interested in the following experi- 
ments of M. Albin Gras, as to the poison which most readil j 
destrojed it : — 

* ^Immened in pure water, the aeams was yet alire after tiffee houxs ; 
inadkie water it mered leehly at the end of time hours ; in Goulaid soln- 
tian it Ured after an hour ; in qUyo oH, almond oil, and castor oil, it sor- 
n?ed mote than two hooia. In croton ofl it was lirag after the kqiee of 
aa hour, hut dead at the end of four ; in lime-water it waa dead in thiee 
foaiteis of an hour ; in yinegar, in twenty minutes ; in alcohol, also in 
twen^ minutes ; hut in naphthaline still more quickly ; in a solution of 
adphnnt of potas^ it was dicadmtwidw minutes; m ^irit of tntpcnlino 
la BiDe BiaBtea ; in a copccptrated solation of hy^iodate of potas% the 
acarnseeased to exist in from four to six minutes; in a scdutionof assenieas 
aeidit wasdead in four minutes ; in sulphuric ac^ diluted with three parts 
water, it died in tinee mramtes ; in pore creosote, «id in eoneentrnted aeift 
sadaJkaBiB^itodBathwasinmwdiBte, Fbwed orem^ eat powdend ad- 
pbor, the ammakale was £o«md dead the next day; and it rsqiiiied to be 



132 DISEASES OF THE SKIN. 

exposed to the vapour of buniiog solplmr for dxteen minuteB before it died.' " 
P. 247. 

Chapter ninth is devoted to those diseases which consist essen- 
tially in hypertrophy of the papill» of the cutis. We regret 
that our limits will not permit us to extract, as we had intended, 
our author's interesting observations on corns, which are well 
deserving the attention of the peripatetic sect of practitioners. 

Chapter tenth, which includes n»vus and purpura, has dis- 
appointed us. A disease so interesting as the latter ought 
surely to have claimed more attention from one who professes 
himself a reformer in diseases of the skin. 

In chapter eleventh, Mr Wilson considers disordered sensibility 
of the dermis independent of local disease. Pruritus occupies 
the whole chapter. 

Chapter twelfth is occupied with the consideration of the 
disorders of the chromatogenous functions of the dermis, the 
most important of which is albinismus. Under this head we are 
surprised to find it asserted that accidental albinismus is only 
met with in the natives of Africa. An interesting case is re- 
corded by M. Alibert of its occurring in a lady, a native of 
France, who became affected at the age of 13. 

In the thirteenth chapter, Mr W. considers the diseases of the 
sudoriparous glands, the most important of which is " sudatoria, 
an excited action of the sudoriparous glands attended with symp- 
toms which indicate inflammatory determination." We doubt 
very much whether this disease has any better right to be 
regarded as a disease of the sudoriparous glands than diabetes. 

The succeeding chapter is devoted to diseases of the sebaceoust 
glands, under which is included molluscum contagiosum, the 
tumours of which Mr W. regards as " normal sebaceous cells, 
containing granular matter, filling them more or less completely." 
This opinion our readers will at once perceive is directly opposed 
to that of Dr Paterson of Leith (Ed. Med. and Surg. Journ., 
vol. Ivi. p. 279), whose views Mr W. combats with some effect. 
He is scarcely so successful, however, in his attempt to establish 
the non-contagious character of the disease. 

Chapter fifteenth embraces the diseases of the hair and hair-fol- 
licles ; among which we find that plague of the nursery, favus. 
Mr Wilson gives the following account of the recent discoveries 
of the nature of the crusts of favus. The interest of these in- 
quiries, and the importance attached to them, must be our apology 
for rather a long extract. 



DISEASES OF THE SKIN. 133 

^Pathology. — ^The yellow substance which constitutes the cmsts of 
&yu8 has been satisfactorily proven, by recent inyestigation, to be an 
oiganic growth of simple structure^ and bearing a marked resemblance to 
those inferior members of the vegetable kingdom, denominated mould. The 
structure of these crusts appears first to have attracted the attention of 
Remak, who had observed, so early as 1836, their composition of ^ fungoid 
filaments.' Professor Schoenlein of Zurich next called them to notice in 
a paper in Muller's Archiv. for 1839, on the Pathology of the Impetigines, 
in which he makes no doubt of the fdngous nature of the substance, and he 
illustrates his communication by a rude figure of the appearance which 
they presented in his observations. In pursuance of Schoenlein's re- 
searches, they were examined by Fuchs and Langenbeck of GrottingeA ; 
more recently they have been studied by Dr Gruby of Vienna, who 
expresses himself to have been ignorant of the labours of Schoenlein. Dr 
Gruby has, moreover, given a clear and lucid description of the growth, 
which he regards as a parasitic plant, and has determined it to belong to 
the genus mycodermis. The following is an abstract of a paper, &om the 
pen of Dr Gruby, on this subject, in Muller's Archiv. for the present year : — 

** * The cup-diaped crust of fisivus is situated upon a depression of the 
dermis, and is covered by a sheath of epidermis^ which is thickest on its 
concave, and thinnest on its convex surface. Immediately within the 
epidermis is a thin layer of amorphous substance, composed of minute 
molecules ; this layer is dense, of a sulphur-yellow colour, and forms a 
capsule, which is in contact by its external surfiice with tlie epidermis, 
and by its internal surfiice with a fungous growth. The parasitic growth 
is attached by means of its roots to the yellow capsule, while its stem and 
branches extend inwards towards the centre of the capsule, and constitute 
the whitish gray and porous contents of the crust. The roots and branches 
of the mycoderm are smooth, cylindrical, transparent tubuli, which divide 
dichotomously from, point to point. The interior of the tubuli is filled 
with a granular substance, and divided here and there by transverse septa. 
At the ends of the branches are situated the seeds of the plant, which are 
of a yellowish white colour, and either collected into an irregular assem- 
blage, or disposed in the form of a garland. The diameter of the branches 
of the myoodennis is i^xi ^ s^t; o^ & millimetre ; that of the molecules 
contained within the tubuli, 19.^99 to j^^^^ mm. ; and that of the seeds, 
5^9 ^ lis '°^^^' ^' Gruby has detected seeds in the follicles of the hair, 
and impacted in the ducts of the sebaceous glands.' 

" To ascertain the degree of contagious power of the mycodermis, Dr 
Gruby inoculated various mammiferous animals, birds, reptiles, and insects, 
but unsuccessfully ; he was equally unsuccessful in his own person, but 
succeeded, after seventy-six attempts, in reproducing the mycodermis in a 
cryptogamic plant. 

** Mr Busk, in a paper entitled ' Observations on Parasitical Growths on 
Living Animals,* in the Microscopic Journal (No. 10), has given an excel- 
lent figure of the mycodermis. He represents the branches as consisting of 
a series of oblong cells connected by their extremities." Pp. 348, 349. 

In the disease mentagra or sycosis, M. Gruby, in September 
1842, announced the discovery of similar cryptogamic forma- 
tions, which constitute a vegetable sheath round the dermic 
portion of each hair. Mr Wilson, however, is more cautious 



134 PISBASBS OF THB SKIN. 

ihaa aom» of our ottirand-out " HiBtologiats/' in pYmg in to the 
theory of the yegetable character of these diseases ; axid r&tj 
properly remarks, that, *' however closely these fungous groirdis 
may resemble plants, their vegetable nature is very far from 
being established/' and concludes with the following very scten^ 
tific opinion of Dr Carpenter : — 

^Dr Curpenter, in his Principles of Physiology (p. 453), q^eakingca 
the BAme snbjeci, remaiks — ' It has been assumed that the ofganisation is 
vegetable, because it (mycodermis) consists of a mass of cells capable of 
extending themselrdi by the ordinary process of multiplication. But it 
umst be remembered that the vesicuhur organization is common to animals 
as well as to plants, being the only form that manifests itself at an early 
period of development in either kingdom, and remaining throughout Ufe in 
those parts which have not undei^one a metamorphosis for q^ecial purposes^ 
Hence, to speak of porrigo favowy or any simiku: disease, as produeed by 
the growth of a vegetable within the animal body, appears to tiie author a 
very arbitrary assumpticm ; the simple fact being, in regard to this and 
many other structures of a low type, that they pieieat the simplest cnr 
most general kind of oiganisation*' " P. 350* 

In the treatment proposed for this obstinate aflEection there 
is nothing novel. 

** TreatfMnt.-^T\iQ indications to be fulfilled in the treatment of &vu8 
are four in number— namely, 1. To destroy the vitality of the parasitic 
growth ; 2. To remore all local causes of irritation ; 3. To remove all 
general sources of irritation ; 4. To excite the diseased hair-follicles to 
healthy action, and prevent the reproduction of the mycodermis." P. 351. 

For fulfilling the first indication, the author recommends 
" impregnating the crusts and bathing the scalp with a mode- 
rately strong solution of bichloride of mercury ;" and that which 
he recommends for the fourth is the tincture of iodine faoraohed 
into the scalp three times a-day. This remedy, first introduced 
by Dr Graves, has utterly failed in many cases in our hands ; 
and we have not succeeded better with that so confidently re- 
commended by Mr Wigan (Med. Gazette, Sept. 15, 1843X 
Beaufoy's concentrated pyroligneous acid. Mr Wibon alludes 
to the great success of the treatment of the brothers Mahon, 
axid regrets that their remedies are still kept secret ; but, if M. 
Diqyarc (on Cutaneous Diseases of Children) is to be credited, 
this is not the case, the following being their method of cure :— 
" The hair is first cut short and then removed by emolKent 
poultices. The head is now frequently washed with soap and 
water, and the inunctions and lotions continued until the scalp is 
completely cleaned. When tiik has been effected, the second 
stage of the treatment commences, the object of which is to 



DISEASES OF THE SKIN. 135 

remove ihe hair slowly and wUhautpain from aQ the points of 
the scalp oocnpied by the fayns. Every second day the oint- 
m^t (No. 1.) is apphed, and its use continued a^KX>rding to tiie 
obstinacy of the case. On the intervening days the hair is 
combed wi& a fine comb to remove the loose hairs. This mode 
of treatment having been eontinued for about a fortnight, a 
dqpilatory powder (No. 2.) is sprinkled through the hair once 
^week ; and e« the following day the hair is combed, and the 
depilatory ointment applied as before. At the end of a month 
or six weeks, a more active ointment is employed every day ; 
hhd, as the disease gives way, the frictions are made only once 
a-wedt, until the redness of the skin has entirely disappeared.'' 

Although the formula of the remedies employed by the 
" Jreres Malum" have been kept secret, yet their composition 
has been very nearly ascertained by experiment, and is supposed 
to be as follows : — ^No. 1. Slaked lime, 8 scruples ; soda of com- 
ffieree, 12 scruples ; lard, 64 scruples. — No. 2. Wood ashes, 64 
parts ; pulverized charcoal, 82 paints. — Lotion. Lime-water, 500 
parts ; sulphate of soda, 185 parts ; alcohol, 24 parts ; white 
soap, 10 parts. 

We are much inclined to recommend the removal of the hair 
by some depilatory ointment and assiduous combing, accompanied 
with frequ^it washing, in the early stage of the disease. When 
the more acute symptoms have subsided, the affected parts 
Aould be touched every third day with pure creosote, and 
covered in the interval with pledgets smeared with an ointment 
composed of creosote, gtt.xxx. ; lard, §i. ; or dipped in the 
liniment recommended for scaly diseases. 

Of the two remaining chapters of Mr Wilson's book, the one 
is devoted to syphilitic eruptions, which we have no room at 
present to discuss; and the other might with more propriety 
have been styled aa appendix, consisting chiefly of additional 
observations on subjects treated of in preceding chapters. 

From the fiiU account that we have given of this work, and 
the numerous extracts with which that is interspersed, our 
readers will be able to form for themselves an estimate of its 
merits. As far as the fulfilment of the object for which it pro- 
fesses to have been written is concerned, we cannot but regard 
it as a failure, the changes proposed in the classification consist- 
ing chiefly in the nomenclature of the orders and genera. Nor 
can we consider such an object worthy either of the talents or 
the opp(»*tunities of observation which Mr Wilson undoubtedly 



136 ON THE DISEASES OF THE TESTES 

possesses. The earnest mind, investigating the pathology of 
this interesting class of diseases, will not now be put oflf by the 
forms and semblances of knowledge. We require a real grap- 
pling with the subject in all its extent. For this task, even in 
the work before us, Mr Wilson shows himself qualified. Let 
him take the step in advance, and we anticipate a glorious 
result, the sign of which will probably be the exploding of his 
own and all other existing systems, and the establishment of a 
new one on a more extended and firmer basis. Meanwhile, let 
us congratulate Mr Wilson on what we must regard merely as 
a first instalment, the numerous excellencies of which will require 
him to exert himself on future occasions, if he is to fulfil the 
expectations which his first volume on this subject has raised. 



A Prctcticcd Treatise on the Diseases of the Testes and of the 
Spermatic Cord and Scrotum. By T. B. Curling, Lecturer 
on Surgery, and Assistant Surgeon to the London Hospital, 
Surgeon to the Jews' Hospital, &c. 

The work heading this article is one of much merit, and is 
written in a very plain, clear, and unpretending style. The 
author's object seems to have been, through every page of the 
work, as he himself states it was, to endeavour to make it as 
practical and as useful as possible. This point he has most 
certainly fulfilled. He has, however, done more. He has 
endeavoured to explain, as far as the present state of our know- 
ledge would permit, the processes by which and the circum- 
stances imder which the different diseases connected with the 
several tissues which compose the organ under his consideration 
are produced and developed. In the treatment of these subjects 
he has not forgotten, but on the contrary he has brought some- 
what prominently forward, the effect which the character of the 
constitution has upon the nature of these diseases, and upon their 
onward progress. It is here that the surgeon, who is desirous of 
advancing this branch of medicine to a higher state of perfection 
than it at present possesses, must labour. It is not by statistics, 
though this has done much ; — ^it is not by a mere knowledge of 
descriptive and relative anatomy ; — ^it is not by the minute de- 
scription of symptoms ; — ^nor is it by the advancing of morbid 
anatomy in the direction in which it has, up to this time, almost 



AND OF THB SPERMATIC CORD AND SCROTUM, 137 

entirely progressed, that surgery is to be really improved. It 
is by studying disease in an entirely different method, but still 
in connexion with these ; by endeayouring to unravel, analyze, 
and make known the nature of disease. To do this, the origin 
and progress of disease must be studied at once chemically, 
microscopically, and physiologically. We indeed grant that 
om* present state of knowledge, in any of these branches, with 
the exception of the last, prevents them from being brought, with 
any chance of success, except in a few rare instances, to our aid. 
Nevertheless, it is not of small importance to be acquainted with 
the correct path along which observers ought to proceed ; for 
then time, continued labour, unwearied industry, and indomitable 
perseverance, are but wanting to carry our undertaking to a 
successful issue. 

The subjects described or spoken of in the work at present 
under our consideration are divided by the author into two 
great and distinct classes : — ^mto that which relates to the 
healthy structure and the healthy functions of the testes, their 
coverings, their ducts, and their vessels ; and into that in which 
the diseases of these parts are described, and their treatment 
laid down. 

The remarks which we propose making on the first portion of 
the work, i. e. upon the part which relates to the healthy 
anatomy and the healthy functions, shall be confined principally 
to a description of the process by means of which the testicle 
passes from the abdomen into the scrotum ; as on this point Mr 
Curling has indeed thrown great light, for which he deserves no 
small credit. 

That it was long known, previous to the time of Haller, that 
the testes, during the greater part of foetal life, are situated 
in the abdomen, is evident from the writings of several of the 
older anatomists : this fsict is also shown by Haller himself, as in 
his Opuscula Pathologica he refers to the circumstance of the 
older anatomists having noticed the abdominal position of the 
testicles during foetal life. However, neither they nor Haller 
were acquainted with the circumstances on which the change of 
situation of the testicles, in the two stages of life, depends. And 
what is very curious and well worthy of remark, is, that al- 
though John Hunter described, to a certain extent with correct- 
ness, the gubemaculum testis, — a part which he had himself 
discovered, — still he did not assign to it its proper use, and from 
this drcumstance was unable to account, with any degree of 



13S ON THB DI&EASE8 OF THB TESTES 

eertaintjr, for ihe descest of the testiele. It wss not watil Mr 
Gurlifig hftd pnbGdted hb exceedingly beaatifidi and highljr 
aeientifie remaito vpoft the scibject, that we possessed m Ihk 
eoaatry any correct knowledge aa to the cause ei the (fescent (^ 
this organ. 

We propose here to enter at some length into one or two of 
the anatomical questions connected with the descent of the 
testicle. This we are induced to do, not only by feeKng- the high 
importance of a right miderstanding of the anatomy oi the 
descent in a sm*gicaf point of yiew, but also because we have 
obseryed that the accounts of this subject m our best works of 
anatomy, are either founded on misappi^ension, or so obscurrfy 
expressed, that it is impossible for the reader to dscover the 
true nature of the descent, particularly in its rda^ns to the 
perit(meum. 

In Hunter^s Animal Economy is contamed a paper upon the 
descent of the testicle, which is distinguished as exhibiting greafc 
truth of description, and a rare power of generaE&ng anatomical 
fSetcts. 

The cremaster muscle (we follow Hunter's account, retainmg; 
as far as we can with brevity his own words), has two very 
different positions in the foetus and in the adult ; in the former, 
it ctgcends^ to the testide, while in the latter, it descends into 
the scrotum to the same organ.* This muscle appeara to be 
composed of the lower fibres of the obhquus intemus and trans- 
rersaKs musdes. The testicles, while in the abdomen, we harei 
found to be connected with the scrotnm by means of a structure 
which passes from the lower border of the testis to it ; to this 
struotore we shall give the name of l^ament or gubemaculum 
testis. This Kgament lies before the psoas muscle, but behind 
the peritoneum, while within the abdomen, and reaches from the 
testis to the groin ; thence it passes directly downwareb into the 
scrotum, in the same manner as the spermatic vessels do in the 
adult, and is there lost. It is hard to say what is the structure 
or composition of this ligament ; it is certainly vascukr and fibrous, 
and the fibres run in the direction of the Egament, whidi is 
covered by the fibres of the musculus testis, which are placed 
immecfiately behind the peritoneum. The testes move down- 

* Fcft thi take of deaxneRs and diatinctnesa^ we ahall call the ciemaater musde, 
while it ascends within the ahdomen to the testide, musculus testis ; and We shall 
erif it cfeoMster mosck when pasting hem the waUs af the abdoMci^ to the teatida^ 
after ^hot oi|;an k siftuated in the saetoBi ; pitmiaiog at tha laaia tiiae that we 
believe them to be, though differentlj situated, the same musde. 



AND OF THB SPBBMATW CORD ANJ> SCSOTUM. 139 

wards imtU their ^dxtr^mity <iomes into coateuA with tile kwer 
part of the abdoiainal pari^tes. That portion of the gubenu^ 
adnm testig which wa» within tiie abdoBien lies aow ia the 
passage from the Abdomen to the scroiiuni, into whidi the testes 
are afterwards to be received. As the tenticle pasees out from 
the abdomen, it in eome degree inyerts the gWbernaoiiliun testis ; 
the external SMr&pe now becoiaii^ tiie internal^ and the internal 
the external ; so thai the pmtoneum, instead of covering the 
cremaster muscle, is covered by it, aaa4 tiius forsos the tunica 



After the testis has got quite tiirongh tiie tend^m of the* ex- 
ternal oblique muscle, it easily acqusres its detenakied station, 
though it commonly remains for some time by die side of the 
penis,* and only by degrees descends to the bottom of the scror 
tmn. Wh^i the testis has entirely descended into the scrotum, 
its tigament is stiU connected with the scrotum^ and lies under it^ 
but is shortened and compressed. 

In the hedgehog, the testes continne throi:^h life to be lodged 
within the abdomen, as in the hiunan foetus ; and are there fas*- 
tened by a similar ligament near to Uie groin. In that a.nimal, 
ihe lowermost fibres of the internal oUique muscle, which con*> 
stitute the cremaster, mount up on the ligament to the lower end 
of the testis. Sometimes in the human body, and very often in 
sheep, the testes do not descend until late in life, or never at alL 
hx the ram, when the testes have descended, the cremaster is « 
yery strong muscle, and covecs the tunica vaginalis ; but in the 
ram whose testes remain in the abdominal cavity, '^ I find that the 
cremaster still exists,'' tiiough it is a weaker musde, and instead 
of pasang downwards, it passes upwards, and is lost near to the 
testis, hx the humaoi fioitus^ while the testes are in tiie ^cavity 
oftheabdomen^ the cremaster is so siMid^ that ^ I cannot Ibwse 
it to my awn satisfaction," either turning ixp towards the testis or 
tommg down towards the 4Mnx»tum. Yet, from analogy, we may 
conclude that it posses up to the testicle ; nnce in the adult we 
find it inserted or lost on the lower part of the tunica vagiaalici, 
in the same manner as in the adult quadruped. 

What is the immediate cause of the descent of the testicles t 
It «annot be the eonqpressiTe force of respiration, the testes being 
in the scrotum before the child has breathed. 



* Professor Owen ttatei, that thli ii the pennanent tituadon of the ttatei fai the 
iiaaaiiHiiMH, IB whidi alao^ as te the Inmam fiBtna, at the peiiod above menlioiied, 
the tnnicm ^aipiialii commnnicatefl with the abdominal eavitj. 



140 ON THB DI6SASE6 OF THE TESTES 

Is the testicle pulled down by the musculus testis ? "I 
can hardly suppose it, because, if this were the case, I see no 
reason why it should not take place in the hedgehog as well as 
in other quadrupeds.'** But even if the musculus testis had this 
power, it could not bring it lower than the external abdominal 
ring.f We have here given a pretty full digest of John Hunter's 
paper on the descent of the testicle. We shall immediately show 
that these observations correspond almost entirely with those 
lately made by Mr Curling. 

We first, however, say a few words concerning the opinions held 
as to the manner in which the cremaster muscle is formed. These 
may be divided into two orders : — 

First, On the philosophical and comprehensive idea, that the 
cremaster muscle is formed in the same way in the human being 
as in the mammalia ; i. e. this muscle is formed at a certain period, 
previous to its being required ; and this formation takes place 
independently of any accidental circumstance. 

Secondly, On the very limited and very unphilosophical notion, 
that this muscle is formed accidentally, by the testicle carrying 
along with it, while passing through the walls of the abdomen 
into the scrotum, a few of the fibres of the internal oblique and 
transversalis muscles. 

The first opinion was, as far as we know, first stated by John 
Hunter, and subsequently adopted by Sir Astley Cooper, who 
says, " The cremaster, as far as I can distinguish it in the foetus, 
passes upon the gubernaculum to the testis." 

The other notion is that held by Cams, Jules Cloquet, and 
indeed generally by anatomists. Jules Cloquet says, in speaking 
of this subject, " The cremaster does not exist before the period 
at which the descent of the testicle takes place ; it is formed in 
proportion as this organ, which is drawn down by the guberna- 
culum, passes from the abdomen into the scrotum," He again 
says, " By drawing down the gubernaculum, we simulate, in 
some degree, the natural descent of the testicle, and form an 
artificial cremaster," There is a reach of thought in the former 



* Here we have a good illustration of the danger under which we lie of either 
falling into error, or of allowing truth to escape us, when drawing conclusions from 
apparently similar data, in consequence of the requisite knowledge not having been 
obtained. This was principally the cause why John Hunter did not discover the 
use of the gubernaculum. 

f We shall immediately point out that John Hunter erred in making this state, 
ment. 



AND OF THE SPERMATIC CORD AND SCROTUM. 141 

view which contrasts well with the narrow and crade ex- 
planation of the latter. 

Haying now shortly stated the opinions held as to the mode by 
which the cremaster muscle is formed, we shall proceed to give 
a pretty full analysis of Mr Curling's views of the anatomical com- 
position of the gubernaculum testis, its insertions, and its uses.* 

The gubernaculum testis Mr Curling describes as a soft, solid, 
projecting body, which is connected above with the inferior ex- 
tremity of the testicle, the lower end of the epididymis, and the 
coimnencement of the vas deferens. The central part, which forms 
the bulk of the gubernaculum, is composed of a soft, transparent, 
distensible, gelatinous tissue — ^primitive cellular tissue. This 
central mass is surrounded by a layer of well-developed muscular 
fibres, which present under the microscope the striated ap- 
pearance peculiar to animal muscular fibre. These muscular 
fibres, which may be traced from the ring to the testis, are sur- 
rounded by a layer of the same tissue as that which composes the 
central mass. We have the peritoneum, except at the posterior 
part, investing all these structures. On laying open the inguinal 
canal, the gubernaculum is, on careful dissection, seen to termi- 
nate in three processes, each of which has a distinct attachment. 
These attachments are as follows : the external and broadest por- 
tion is connected to Poupart's ligament, in the inguinal canal ; 
the middle forms a lengthened band, which escapes from the 
external abdominal ring, and descends to the bottom of the scro- 
tum, where it joins the dartos; the internal process passes 
directly inwards, and is attached to the os pubis, and to the 
sheath of the rectus muscle. These attachments, Mr Curling 
Bays, he *^ has succeeded in tracing out, before the testicle has 
descended, at different stages of the process, and inunediately 
aflier its completion, when the fibres have assumed the situation 
of the cremaster muscle," of the identity of which with the 
cremaster, he says, no ** doubt can continue to be entertained.'' 

When we compare this description with John Hunter's, we 
learn how nearJhBi fine observer came to the truth. When the 
facts were not snffident, with what a power of generalizing 
did he bring to his aid the facts observed by him in com* 
parative anatomy I The microscope was little lued in his day, 
and was not used at all by him ; he could not therefore prove 

* These Tiewfl are alflo conUined in » pq»er bj Mr Cttrliog, fo the Blediol 
Gaiette, April 1841, << Od the Stractme of <he OobcnuieiiltUDy md oo the Vtaemt 
of the TutiM In the Fotni*** 



142 ON THS DISEASES OF THB TB8TS8 

from dir^t obserTatioa the correctness of his belief of the 
existence of the musculus testis, and that it subsequeniJj becomes 
the cremaster muscle. He, howeyer, observed that in the in- 
ferior niammalia the musculus testis did become the creiaiister, 
ajid thence he c<»ichided from suiabgj wha4i Mr Curling has 
proved by direct observation. 

Here we cannot refrain from sayii^ a few w<»xb upon the 
doubt which has lately been thrown upon the existenee of hkib- 
cular £bres in the gubernaculum. This doubt arises from a 
acepticdsm of the capability of the microscope to ^oahle us to 
distinguish definitely muscular Sbre from other tissuea. TUn 
scepticism is not at all warranted. We most readily grant, asmI it 
would be beneficial if it were more generally allowed, that in tke 
prosent state of our microscopic knowledge^ we are unable to 
distinguish many tissues from others which hare very difierent 
properties, but in this catalogue muscukyr tissue eaanot be phuad. 
Thk organic el^aent has distinct and peculiur microscopic pro*- 
perties, which prevent it from being mistaken for any othfir 
animal tissue. It was mentioned above, that Mr Hunter ob- 
awved the p^sist^ice of the gubemaculum in the scrotum in the 
aduU. In this statement he is supported by Mr Curling, wIm 
atates, '' that the middle attacbm^oit of the gubemaadum, which 
may be traced to the dartos at the bottom of the scrotum, gradu^ 
ally wastes away, and soon becomes indistinct ; slight traees, 
howeYex, of this attachment often renaiii imlil the latest period 
o[ life. After death, in dragging the testide of an aduH out of 
the serotum by pulling the cord, the lower part of the gland, 
which is uncovered by serous membrane, is often found cooiifieted 
to the bottom of the scrotum by a band of firm aad dense ceUniar 
tissue, which requires division with a scalpi^ in order to eompleto 
the s^M^ration. I b^eve this band to be tiie remains of the 
middle attachment of the gubernaculum/' 

We shall now finish our analysis and remarks on the first part 
of Mr Curling's work by explaining his view of die process by 
which the testicle is made to descend into the scrotum. This 
process takes place in the same way in ihe human fisetus as in 
some of the rodentia. Previous to the commencement of the 
seaaon of sexual exdtemi^t, the testicles in these animak, as for 
exanrple in the mole, are ^tuated in the abdomen. These glanda 
are subject to remarkable periodical enlargement during the 
season of copulation, when tiiey are drawn downwards by the 
musculus testis to the external rings, where they are, by the ex^ 



AMD OF THE SPBRMATIO CORD AND SCROTUM. 143 

pnlfflre actions of the diaphragm and abdominal mnsdes, pro- 
truded without the abdomen, and are contained within the 
cremasteric pouches which have been formed by means of the 
iayersion of the gubernaculiun and musculus testis. In other 
words, tiiie peritoneum, which formed the external surface of the 
gubernaculum, now forms the internal surface of the cremasteric 
sac, and in this way we haye the tunica vaginalis produced. As 
the testicles diminish in size, which they do after the season of 
sexual desire, their muscular coverings contract, and they are 
carried up to their former situation in the abdomen, the peri- 
toneum becoming again external, and each recently formed cre- 
masteric musde again the musculus testis. A process exactly 
aimikr to this takes place during the descent of the human 
testicle. The musculus testis contracts and pulls the testicles 
downwards, first to a level with the external and internal inser- 
1i<His of the muscles ; they are then pulled gradually into the 
scrotum by means of a process of contraction which is taking 
place in the middle insertion. By means of this process the 
portion of the gubernaculum testis which has descended below 
its external and internal insertions becomes necessarily inverted, 
L «. the peritoneum which covered the musculus testis now be- 
coflaes iaiernal to that structure, whik that structure has taken 
the relative position of the cremaster muscle. We have thus 
fonned the tunica vaginalis and the cremaster muscle. This 
eipknatioA (d the manner in which the cremaster nrasde is^ pro^ 
daced is at one with that held by John Hunter. 

We have seen that John Hunter was unable to account for the 
deaceni (tf the testicle. " It is difficult," aa Mr Gurhng well re- 
marksy '' to understand why, after arriving at the former coDr- 
viction, chiefly from analogy, he wad not induced by the same 
process of reasoning to conclude, that a muscle capable of draw- 
ing down the testicle in g^mmAlfl, would be adequate to acccnnplish 
die same purpose in the foetus." He, however, did all but this. 

We oonelude our remarks for the present on this subject in 
the f<^ofwing words of Mr Curling : — 

*'I see no i^ason to doubt that the cremaster diacliargetf tfce same office 
in the human embiy o, as that which it undoubtedly perfonns in ontasa 
anhDab ol a paiticular seoKm. The fibres pioceecGng from Poupart's Uga- 
meat and the obliquus intenras tend to guide the gland into the inga jnal 
canal, those attached to the os pubis to draw it below the abdominal ring, 
and the process descending to the scrotum to direct it to its final destination. 
As the deaceat approaches completion, the nraseulaor fibres which perform 
so hnportant a part in it gradually become everted, assome new rektiona, 



144 



ON THB DISEASES OF THE TESTES 



inyest the gland, and, instead of drawing down the testicle, acquire the new 
functions of elevating, supporting, and compressing it." 



Fig. 1. 



Fig. 2. 




Fig. 1. 
A Peritoneam — B Nipple-shaped prolongation of do. — C Testicle lying behind 
Peritoneum in Abdomen— D Middle insertion of Gubemaculam testis — ^£ Scrotum, 

Fig. 2. 
A Peritoneum — B Peritoneum prolonged into Scrotum, forming the tunica vagi- 
nolis — C Testicle in Scrotum lying behind do.i*-D remains of middle insertion of 
Oubemaculum — ^E Scrotum. 

The descriptions given regarding the descent of the testicle 
into the scrotum, by almost all those who have written on the 
subject, are such in our opinion as to convey the idea that the 
testicle, in its descent, acquires three serous coverings, — the one 
which it had while within the abdomen, the other two on its de- 
scent into the scrotum. " In this descent," says Mr Morton, for 
example, '* they bring along with them the same partial covering 
from- the peritoneum which they had when situated just below 
the kidneys, which, with the production from the peritoneum, 
already formed in the scrotum for their reception, constitutes the 
tunica vaginalis testis."* We do not hesitate to state, and that 
from our own personal observations, that no sac is prolonged into 
the &croi\xmy previous to the descent of the testicle ; but that this 



* Surgical Anatomy of Inguinal Hemis, the Testes and its Coverings, by Thomas 
Morton, 1841, p. 280. 



AND- OF THE SPERMATIC CORD AND SCROTUM. 146 

organ coming down from the abdomen, brings a portion of the 
peritoneum with it, and in this way the tunica vaginalis is pro- 
duced. While the testicle is still within the abdomen, a small 
nipple-like projection of the peritoneum, in the direction of the 
canal, is all that as yet represents the tunica vaginalis, subse- 
quently formed in the scrotum. The testicle, always mtimately 
connected to the peritoneum, gradually descends, losing its attach- 
ment to the part above, and acquiring a new attachment to the 
part below, until it comes to the level of Ihe little projecting 
pouch, behind which it passes, and carries it down with it to the 
scrotum. 

From the space occupied in this review by our remarks upon 
Mr Curling's description of the descent of the testicle from the 
abdomen into the scrotum, we shall be unable to enter at any 
great length into a consideration of the second or principal part 
of the work. We shall, we fear, be obliged to give but a very 
general analysis of it. 

The first chapter of this part of Mr Curling's work considers 
and illustrates several interesting cases of congenital malfor- 
mations and imperfections of the testicles. This chapter de- 
serves no small praise. It is at once interesting, curious, and 
highly practical. 

Man's frame is a complex machine, being composed of several 
organs, each of which has its own peculiar office to fulfil, and 
they are all so dependent on each other, that the irregular action 
of one soon perverts or destroys entirely the healthy actions of 
the rest. Besides this, there is between some organs a much 
closer connexion than between others. Such a connexion has 
been proved by observation to exist between some part of the 
nervous centre and the genital organs. Of the nature of this 
connexion, however, we know nothing. Hippocrates says of the 
Scythians, that when they were sick, they opened a vein behind 
each ear ; when the blood had flowed from them, they felt them- 
selves overcome by feebleness, and went to sleep. On waking, 
some found themselves cored ; bat this was not the case with all 
of them. " For my own part, I conrider that this method of core 
was very hurtful to them ; because, behind the ears there are 
veins, the section of which produces impotency." Baron Larrey 
states, that he has found this remark of Hippocrates confirmed 
by the Egyptians. We have also contained in the works of 
many authors cases which seem distinctly to prove that a close 
ooDnexicMi of some l^ind exista between the encephalon and the 



146 OS THE DISBASBS OF THB TESTES^ &€. 

flmctionft of the testes. We shall quote the following ca^ from 
Mr Curling's work, in illustration of this point : — 

^ A few jean ago, a man who had met with an injiuy of this description, 
which had been fdllowed by wasting of the testea^ and tha deyelopment of 
tumoun on each side of the chest, resembling mamme, presented himaelf 
at the different ho^itals in London. I saw him in Biuch 1828, at the 
London Hospital, when he had the appearance of a man who had seen hard 
service. He stated that he was abont fifty-nine years of age, a married man, 
and the &ther of seyeral children. He had belonged to the legion in the 
Qaeen of Spam's service. About two years and a half previously, in an 
attempt to Jump over a trench in a retreat, he fell backwards^ and injured 
the posterior part of his head. WhUst on the ground he received a bayonet 
wonnd on the left nde, and a sabre cut on the forehead of the sane ode^ 
He recovered &om these injuries, and returned to England. Binee the 
accident he had completely lost his virility. He had no desire for sexual 
connexion ; his penis had dwindled in size ; his right testis had gradually 
wasted, and was no larger than a horse-bean, and the left gland was also a 
good deal diminished in bulk. The skull, at the oociput, seamed somewhat 
flattened." 

Mr Curling has the following remarks upon this and other 
oases of a similar kind which he has quoted i-^** We cannot doubt 
that in these cases the loss of sexual desire, and the wasting of 
the testes, were the direct results of the mjury of the lorain; and 
they go far to prove the essential dependence of the functions of 
these glands upon the cerebral organ." 

The inflammatory and organic diseases of the testes which are 
treated of here, are spoken of in the following order :— First, the 
diseases of the protective parts or tunics, L e. the tunica yaginali& 
and tnnioa albugenia; then the diseases of the glandular or 
secreting structures ; and, lastly, those of the excretory parts. 

We shall conclude our somewhat general remarks on tiiis por- 
tion of the work under consideration, by the following excellent 
and practical observations :~^ 

^ A carefbl examination into the merits of the various modes of efiecting 
a mdical cure of hydrocele fully establishes the superiority of the treatment 
by injection. The great error formerly committed by surgeons in endea- 
vouring to excite a high degree of inflammation, arose from a mistaken 
view of the object to be attained ; for not perceiving that the exndant 
secretion could be correeted by altering the action of the vessels of the part, 
they thought it necessary to obtain the obliteration <^ the natural pi^^ity, 
which, moreover^ they endeavoured to effect by producing suppurative 
inflammation of the membrane, instead of by the milder process of adhesion. 
Injection has now been largely tried in this and other countries, and expe- 
rience warrants in assertmg that, though it is not iafiillihle, of all tha 
plans hiihsrto practised, it ^ombmes the greatest number of advantages^ 
The pain attending it is slight^ its effects are mUd, and at the same time 
tolerably sure ; if properly performed, it is free from danger; and it fre- 
quenUy succeeds without altering the natural eon^tfon of ihe ports.*^ 



ON THE STRUOTURB OF THB NRRVOUS SYSTEM* 147 



Part IIL— PERISCOPE. 



ANATOMlr AND PHYSIOLOGY. 

On M0 Sirmeiure^ BehtioMf and FuneHant cf the Nerwue SyHem. 

[Continued from our last.] 

'^^imetiont qfthe Brain and Nenxnu Cord.— Although I lutye now pointe4 
out the exutemce of fibres in the nervous cord of myriapoda and arachnida, 
which lead us to the conclusion that the doctrine of the individuality w 
i^ecial function of each fibre is coirect ; that there are fibres in every nerve 
4erived from two distinct portions of the cord^ which, from their direct 
coDUBunication with the brain, from one end of the body to the other, ave 
believed to minister to volition and to sensation, and that other fibres also 
exist in the same nerves, that have no communication whatever with that 
oigan; and further, that some of these which are extended tnmsveraely 
across the body, influence both sides of those individual segments to whi<^ 
they are distributed, and those only, while others combine in action two 
or mote contiguous segments, but only by direct influence on one side of 
the body ; — ^it yet remains to be shown by experiment, whether the assign- 
ment of certain functions to tliese parts of the nervous ^stem^ in these in- 
ferior animals^ is correct ;'— whether the results of experiments on theas 
worm4&e beings agree in principle with the experiments already made by 
many physiologists on the verteforated classes, and with those which thp 
pathology of disease has afforded in man himself ;-^whether, as leading to 
these important results, they coiucide with the first experiment made on 
one of the oruatacea, conjointly by Dr Marshall Hall and myself, in thfi 
spnng of 1834^ and with others subsequently performed by Valentin on the 
same animal, and afterwards repeated by Dr Baly and myself in 1840 ; ancl, 
lastly^ whether the seat of sensation and volition is confined entirely to the 
supra-oesophageal ganglia, the brain in these articulata." 

« Thee questions that require to be examined are—* 

Utf Whether sensation and vdition are confined to the supraKCBSc^htgeal 
gasglia, the brain» or whether they exist also in the first suboesophageal 
ganglion, or in the other ganglia of the cord ! 

2d^ Whether these functions are destroyed by destruction of the bram ! 

8d^ Wheth^ there is any direct evidence of sensation in a portion of the ^ 
eord that is iusolated from the brain ! 

4dhy Whether the movements in these animals, when deprived of the 
bram, are id^itical with those of the Crustacea and Tcrtebrata !" 

^^EapeHment 1. — The front of the head, antenna, eyes, and brain, weve 
at onoe r^noved with a pair of scissors from an active adult specimen. 
Widle held between my fillers there were powerful contortions of the 
whole body of the animal, and when placed on a table, it moved rapidly 
forwards as in the usual mode of locomotion, and continued to do so for a 
fewminiites ; but the motions gradually became slower and slower, and at 
last were «o feeble that onwaxd progression was suspended, although tho 



14S ON THE 8TEU0TURB OF THE NERVOUS SYSTEM. 

legs were still feebly movedy as in walking, for nearly half an hour, when 
their motions entirely ceased. There was no evidence whatever of sensa- 
tion or volition, although the suboesophageal ganglion and cord were un- 
injured. During locomotion the body moved in a direct line and always 
forwards. When it met with a slight obstacle it climbed over it, or when 
too high to pass over, the body stood directly opposite it with the mutilated 
portion of the head in contact with the obstacle, and the locomotive actions 
of the limbs gradually increased, apparently by the excitement of contact 
with a foreign body against the lacerated surface of the head.'' 

*< When the movements of the limbs ceased, the body was maintained in 
its natural position upon them for several hours, untU fresh mechanical ex- 
citement was applied to it, when the locomotive actions were repeated." 

" Experiment 2. — The head was removed from the body in the third 
segment, the second of the trunk, and acts of locomotion were performed 
by the body precisely as in the last instance, and were always re-excited in 
the same manner. When turned on its back the body was instantly ex- 
cited to violent contortions until it had regained its proper position, and 
stood supported on the legs, which were extended, and slowly moved as in 
locomotion, after it had continued to walk for four minutes. When the 
anterior cut extremity of the cord was irritated with a needle, locomotion 
forwards was again induced. Pressure on the anterior segment excited it 
most readily. Motions of the legs were instantly excited by simple contact 
with any foreign body, and those on both sides, anterior and posterior, were 
moved, but insufficiently for locomotion. Violent contortions were always 
induced when the body was placed on its back, until its proper position was 
regained ; but the motions of the legs were not excited by a current of air 
directed on them from a blow-pipe until after the lapse of a few seconds ; 
but there was always a slight convulsive motion of the body after each sudden 
current. The legs were less excited, during the first few hours after de- 
capitation, by pressure on the posterior than on the anterior segments.- * 

** Experiment 3. — ^The body was divided in the seventh segment while 
the animal was running briskly. It continued to move forward for a few 
minutes, but the motions gradually became slower and slower, as in the 
preceding experiments. They were actively re-excited by a brisk sliake of 
the table, but soon became quiet, with slow but very gradual motions of the 
legs. Progression was always quickly reinduced by pressure on the anterior 
segments, and this was more active tlian when applied to the posterior. It 
was always reinduced when the cut extremity of the cord was irritated 
slightly with the point of a needle. At the expiration of an hour from the 
making of these experiments, the atmosphere continuing at about the same 
temperature (56° Fahr.), the excised heads of Nos. 2 and 8 were still living, 
and exhibited acts of volition, and that of the latter, with the segments and 
legs attached to it, made attempts to walk. Both of these moved the antenne 
briskly, and touched objects that were near to them, as if to feel and 
appreciate." 

" Experiment 4.— The body was divided at ihefimrteenth segment while 
running. The anterior part exhibited all the voluntary actions of the perfect 
' animal, those of touching, avoiding, or seeking an object, and also of locomo- 
tion, but its movements were slow and were made with difficulty. This 
arose from want of proper counterpoise of the body, since when that was 
supplied by the proximity of the individual to the upright surface of any 
object, locomotion was well performed. The remaining portion of the body 
was then divided into two parts ; both of which were instantly excited to 



ON THE STBUCTURB OF THE NEEVQUS SYSTEM. 149 

moyements of the legs when irritated, but without any power of locomotion, 
or ability of either part to support itself in its proper position. The motions 
of the legs were readily induced by a current of air, or when the segments 
were compressed, or the cut end of the cord touched with the point of a 
needle. At the expiration of nine hours the anterior division of the body 
with the head was dead, and not the slightest voluntary or reflex action 
could be excited in it by any means. But the middle division of the same 
individual was readily excited to reflex actions of the legs and contractions 
of the segments, by compression of the segments, by irritation of the cord 
with a needle, and by brisk currents of air from a blow-pipe. These re- 
flected actions were much stronger in the third or posterior division of the 
B^;ments, and were all induced by similar means. After twelve hours they 
were feebler in the middle division of the segments, but were even more 
leadlly excited in the posterior. After eighteen hours they were scarcely 
perceptible in the middle division on the application of the needle, and not 
at all on compression ; but they were still easily induced in the posterior, 
and continued to be so in the four or five posterior pair of legs even at the 
expiration of twenty-four hours. The temperature during the interval was 
not higher than 64° Fahr." 

{To he continued.) 



Eopperiments by M. Chatin on the Mode by which Poisons are Absorbed. 

If no one doubts that the absorption of the nutritive elements is effected 
by means of the chyliferous vessels, two opinions are however held as to 
how poisons are absorbed from without into the system. According to one 
of these opinions, it is believed that the chyliferous vessels absorb indifier- 
eaUXy all fluid substances contained in the digestive cavities. On the other 
hand, the experiments of several physiologists, and especially those of 
Magendie, support the other notion, viz. that the absorption of poisons is 
efiected only through the venous system. M. Chatin has made a series of 
experiments for the purpose of proving the correctness of one or other of 
these opinions. After having poisoned a dog with arsenious acid, he obtained 
arsenic from the blood taken from the heart and the large vessel, while the 
chyle removed firom the thoracic duct did not furnish the slightest trace of 
that poison. The same experiment repeated with tartar emetic led to the 
same results. From these fEicts, with others of a similar kind, M. Chatin is 
led to believe that poisonous substances are never absorbed by the chyli- 
ferous vessels. — Stances de V Acadimie Royak des Sciences, Archives Gen^rales 
de la Medecincy Avril 1844. 



SURGERY. 



On the General Laws of Displacement of Bones in Fracture. 

In the Annales de la Ghirurgie there is a paper upon the above subject by 
M. Edouard Lacroix, ex-Prosecteur de la Faculte, &c. The object 
of the paper is to point out and illustrate a principle, which the author 
believes to have a greater influence in producing the various displace- 
ments in fractures than the weight of the limb, the obliquity of the 
fracture, the action of the muscles, and the other causes which have 
generally been regarded by surgeons as the active agents in producing these. 



150 ON THE OBNERAL LAWS 

He states thai he was led to pay attejfttion to the sabject by observiiig how 
frequently the dispLioemeiftts met with in praotioe were at vananoe with 
those which authora^ led by the known action of the muflcle% had been in 
the habit of describing them to be, 

" Smgeons^*' he 8ay% ^^ have very properly taken into consideration the 
obliquity of the fracture and the weight of the limb ; but after these, they 
have been in the habit <tf considering the muscles as acting wiUiout any thing 
to counterbalance or modify the direction which they give to the fragments" 
The fact, he remark^ which struck him in the oouise of his observatkms^ 
was the great resemblance existing between the bones in which deformity 
had been produced by badly set fractu^ and those in which it had been 
the consequence of lickets, — a resemblance so gfeat in some instances that 
it was difficult at fiM to say to which of the two it was to be letored. *' I 
was thus naturally led," he continues, *^ to draw a comparison between those 
)M>nes which had undeigone some change in their powers of resistanoe &om 
ihese canses. It was eyident that the only difference estisted in the gtisater 
or less fiwiUfy with which the bones yidded to the action of the muscles. 
Jb rickets^ the Curve is gentle and equal, because the bone yields but dowly, 
and in all parts equally ; whereas in fracture, it is abrupt and llmitsd to the 
part where the bone is deprived of its power of resistance. 

The fractured bone, however, he says, must be subject to the same laws 
of muscular contraction, because its extremities are not entirely free, — 
fibrous and muscular bands necessarily limiting the displacement of the 
fragments. This condition of parts^ he concludes^ constitutes a very great 
difierence between fractures and dissected prepamtiidlis^ ki which, after isola- 
ting the knnscles and depriving the bone of its coverings^ surgeons faavte 
be^ in the habit of studying the action of the muscles upon th^ diWded bone. 
M. Lactoix believes that the natural curvatures of bones are dependefe^t upon 
mufloular contractioik, and tiiat these curves are identical with thote WUch 
we meet with in rickets and &acture%*^the latter only differing firom ike 
forme/ in their being more marked. 

He then concludes generally, ^Uhat displacement of the fractured bones 
takes place according to angles which correc^nd in plane tod diredbion with 
the natural curvatures of bones." Hesupports his doctrine hy tefereDee 
to the prepinations in the museum of Diq^uytrea, r^rting to ikexbL by 
numb^. We have not space to follow him throughout, but shall give one 
or two of his illustrations in different fractures. Before doing so, ^we vet , 
we may remark, thafc we cannot consider the principle which M. Lacroiic 
lays down to be bo geneital in its applidEition as he would lead us to believe.; 
although we are willing to grant that it exerts an influence, and perhaps a 
very powerful one, in determining the nature of the displacement. We 
cannot help thinking that M. Lacroix has been too anxious to lay down as 
a general law what ought only to have been regarded as one amongst the 
many causes which lead to the various displacements in fracture. He has, 
if we may judge from his statements, been very naturally led to do so from 
the examination of the preparations to which he has had access ; but had 
he <extended his inquiries, we have no doubt that he would have been led 
to tfttaoh to his observation its true value. We shall advert to M. L.*s 
observaticms on two fractures only, as confirmative of what we have said. 
The filfet we shall refer to is that of the clavicle, and the second that of the 
shaft of the femur. M. Lacaroix, we may remark, takes the descriptions 
t>f Biohat and Boyei^ ab representing the opinions of the generality of sur- 
geoiii. 



OF DISPLACEMENT OF BONES IN FRACTURE. 151 

In the w&rka of both of these aathoTS we find the displacement of the 
extevnal portion of the clayicle in fracture described as being downwards^ 
inwards, iufdfifrwird». ^ If," says M. L., ^ we take the deseriptiona of tkcfe 
anthoTB as the most detailed and exact, we find that they can only hare 
described those fractures situated at the inner third of the cavide* J£ we 
pay attention to the law which I have laid down, we find that wl^^n thei 
fiactare is situated at the union of the two external with the internal third, 
the displacement of tiie external fragment is forwards ; whereas, if it be 
BMted at the union of tho two internal with the external third, the aommial 
portion is carried backwards, and that whatever be the direeticMi of tha 
obliquity of the frseture.** In t^is ft»<ture the real state of mattcirs ap« 
peasi to bear out what is said by M. Laoroix. We have examined a good 
many prepaiwtions of fVaeture^ daviole, and we have found, we may almost 
say without exception, that the fact is as stated by him. The fineture in 
the outer curve, we mav i>emark, is by ftff the most Qomm<»i ( in fi|o4, it 
is rare to meet with ftaoture at ^e laner ^ird. Th^ finotures of ^e shaft 
of the femur do not, we believe^ contend sq eloeely with the des^iptiona 
given by ouf author ; in Ud^ the exeeptions are so frequent as to deprive 
his ttKplanation of aXL claim^ to* the tHle of a eeneial law, ** The examina* 
tion ef the numerous preparations,** says M. Laovoix, *^ m the museum of 
Dupuytren, shows that wbatevep be the seat of the f^oture — whether it be 
simple or comminuted — the upper fragment is placed in front, and forms 
ia this direction a projection more or less eonsi^evable, more Mr less acute, 
and pomted outwards^ The extremities of both superior and inferior por- 
tions are directed outwards, and the axes of th0 fragments form an angle, 
the concavity of which looks inwards.'' M. Laoroix appears to have ex- 
amined the preparations in the museum of Dupuytren only, and we have 
no doubt that in so fiir as they went he was amply home out by them ; but 
this just shews the danger of forming general kws on limited observations* 

In our own hiquiries into this subject, we have by no means come to the 
same conclusion ; in fiict, we find the eases which deviate from his general 
law ^most as numerous in some respects as those which concur with it. 
In thirteen preparations, for example, taken from a private museum, we 
ind the followhig to be the actual state of the fiust :— In nine^ the superior 
fragment was anterior, as described by M. Lacroix, and in four posterior. 
In^w, the curve was outwardly as described by him ; in «m?, imoardfy show-. 
ing a result very difierent from what we should have been l^d to expeet by 
him. We have also run hastily over the preparations in some otheor 
museums, and in them likewise we find the exceptions very numerous. 

The oUiquity of the fracture, and its seat, as well as th<$ mode in which 
it has been produced, appear to exert a much more powerful influence 
than the law laid down by our author. This was clearly shown in many 
of the preparations to which we have referred above. It was evident, for 
instance, that it was to the direction of the obliquity of the fracture that 
in so many cases the inferior fragment was anterior to the upper one, 
instead o£ hemg posterior to it, as described by M. Lacroix ; the obliquity in 
these cases passing from behind upwards and forwards in the lower fragment, 
and the reverse of course in the upper. In like numner, the ipfluenoe of 
the seat of the fracture was well shown in these ; the fracture in almost 
all those in which inversion or the curve inwards existed— constituting, aa 
we have sdd, the majority— -being through the lower part of the shaft, the 
adductors being thus allowed to act almost without antagonist. 

We do not tbmk it necessary to follow M. Laeroix further in his observar- 



152 ANEURISM OF THE ILIAC ARTERY. 

tions. We have pointed out sufficient grounds^ we conceive, to show that 
the explanation which he gives is by no means entitled to the appellation of 
a general law, but can only be regarded as one amongst many causes which, 
imder certain circumstances, determine the character of the displacement 
in fracture. 

Case of Ligature of the Common Iliac Artery for Aneurism of the External 
Iliac, By Richard Hey, Esq., Surgeon to the County Hospital, York. 

We insert the following case because we believe it to be the first instance 
in which the common iliac artery has been tied successfully, in this 
country, for aneurism. This artery has been tied repeatedly by different 
surgeons, but only once successfully for aneurism, so &r as we can recollect, by 
Dr Mott. It was first tied by Professor Gibson, in a case of gunshot wound, 
but the patient died on the fifteenth day. It has likewise been tied by Mr 
Crampton of Dublin, and Mr Syme, but in both the issue was unfortunate. 
In the latter case any other issue could scarcely have been hoped for, as 
mortification had commenced previously, requiring subsequently the ampu- 
tation of the limb. The ligature of the artery had been performed as af- 
fording a chance, although a desperate one, of saving the life of the patient. 
In 1833, Mr Guthrie tied this vessel for a tumour supposed by him to be 
aneurismal, but which proved to be of a medullary chiuacter. 

^ Mr Taylor, aged forty-one, residing at Acomb, near York, seen in consulta- 
tion with Mr Nelson, surgeon, and Mr EUis, on the 22d November 1843. I 
received the following history of his case : — 

^ On the 10th of this month Mr Taylor perceived a stifiness and uneasiness 
in the left groin, and on examination found a small hard tumour imme- 
diately above Poupart's ligament, midway between the anterior superior 
spinous process of the ilium and the tuber of the pubis. Having been 
occasionidly subject to scrofulous tumours, ending in suppuration, he sup- 
posed this to be an enlarged gland, and therefore at first took but little 
notice of it ; he showed it, however, to his medical attendant, who pre- 
scribed suitable remedies for its removal. On the 13th he was suddenly 
attacked with severe pain in the tumour, and on the following morning it was 
found to be much increased in size ; and now, for the first time, a decided 
pulsation was observed in it ; pulse 90. From this time until Uie 22d the 
tumour made perceptible advances in size daily, accompanied with pain 
along the course of the anterior crural nerve. 

^' November 22. The tumour is now the size of a pretty laige orange ; 
the impulse very strong. It was, however, easily emptied by moderate 
and continued pressure, instantly filling again when the pressure was re- 
moved. Pressure on the aorta had the same effect, but in a lesser degree. 
When the base was grasped, the fingers at every pulsation were forcibly 
separated, and equally so on every side. There was clearly aneurism of the 
external iliac artery. 

^ November 28. The tumour rapidly increasing in size ; and as there 
seemed to be no alternative but placing a ligature upon the common iliac 
artery, or speedy death, I thought it my duty no longer to delay acquaint- 
ing him fully with the state of the case : he was not prepared, however, 
at present, to decide upon the subject. 

" November 30. The tumour now, from having a round and uniform 
surface, had become conical^ like the pointing of a large abscess, the skin 
also much thinner, red, and shining. We therefore uiged upon our 



ANEURISM OF THE ILIAC ARTERY. 153 

patient the necessity of a speedy determination ; and at his request, my 
brother^ Mr William Hey, of Leeds, was requested to meet us in consulta- 
tion. 

<< December 2. We met this day, and found the tumour within the last 
forty-eight hours had so much increased as to render any further delay of the 
operation extremely hazardous ; and as Mr William Hey concurred with 
us in the propriety of attempting to save our patient's life by the means 
already proposed, and as he was now quite willing to submit to it, we 
determined to wait no longer than the following morning. 

'^ Sunday, December 3. I proceeded to place a ligature on the common 
iliac artery. It seemed out of the question to attempt tying the external 
iliac, because, from the very large size and extent of the sac, it was evident 
that there would not be room for a ligature between that and the bifurca- 
tion of the external and internal iliacs ; and in addition to this, the pro- 
bable state of that artery made it unwise to run such a risk, even if it had 
been practicable. 

^ There were present at the operation Messrs Nelson and Ellis, Mr 
William Hey, and Mr Teale, of Leeds ; Mr Dodsworth and Mr Reed, of 
York ; to whose kind and very able assistance I feel deeply indebted. 

*^ The tumour now occupied the whole of the left iliac fossa, its base 
projecting considerably below Poupart's ligament inferiorly, and superiorly 
extending to within less than an inch and a half from the navel, being six 
inches across from above to below, and six inches and a half from side to 
dde ; projecting also from the plane of the abdomen fully three inches. 

** The patient was placed on his back on a mattress, his shoulders mode- 
rately raised. The incision was commenced two inches and three-quarters 
above the navel, and exactly three inches to the left of the median line. 
This was carried down moderately curved to the base of the tumour 
about six inches, and was afterwards enlarged by an angular continuation 
one inch and a half in length. The fibres of the external and internal 
oblique muscles and transversalis being successively divided, the transver- 
salis fascia was readily raised by means of a director, and carefully opened 
out through the whole length of the incision. The 'peritoneum now 
protruded in some measure ; it was, however, kept down without much 
difficulty ; and being gently drawn towards the opposite side, I was 
enabled slowly to insinuate my fingers behind the peritoneum, gradually 
separating it from its cellular attachment to the parts beneath. The 
common iliac artery was easily reached, and upon compressing it with the 
fingers, the pulsation in the tumour ceased at once. A little time was 
occupied in scratching through the sheath of the artery with the point of 
the aneurism needle ; this being accomplished, the needle was passed 
under the artery from within outwards, armed with a double ligature of 
staymaker's silk, waxed. By holding aside the peritoneum and viscera, 
we now obtained for a moment a view of the artery, and ascertained that 
nothing else was included in the ligature ; this being tied with the fingera 
close down upon the artery, all pulsation in the sac entirely ceased, and 
never afterwcu*ds returned in the slightest degree. The exact position of 
the ligature was, I believe, an inch below the bifiircation of the common 
iliacs. The wound was closed with six sutures and strips of adhesive 
plaster ; and over the whole a coating of lint dipped in strong mucilage. 
Time, 26 minutes. The patient was now a good deal exhausted, although 
80 little blood had been lost that it had not been necessary to take up a 
single bleeding vessel ; he vomited also some brandy and water which had 

V 



154 MATERIA MEDICA AND BIETETICS. 

been giren to him during the operation. He took, however, a cup of 
boiled milky which was retained. 

*^ Evening. Patient had been very restless and uneasy after the operati(m 
for some houn. A camphor draught, with 26 drops of Battley's sedative, 
had had the effect of composing him. There was now moderate reaction, 
pulse 90. The wound continued stUl very uneasy/' 

By the 4th January the patient was quite well.-^Pr(w#iido/ MeHcai and 
Surffieai Journal, No. 5, May 1, 1844. 



MATEMA MEDICA AND DIETETICS. 

InoeukUien wiih Tartar Emetie io produee a Cmmter^IrrUant ErupHem on the 

Skin, 
Dr Debourob, in the ^ Gazette des Hopitaux" for Januaxy 1844, pro- 
poses to avoid some of the inconveniences of the tartar emetic ointnient 
by inoculating the skin with tartar emetie. He puts a pinch of tartar 
emetic on a piece of glass, and moktens it with water ; then taking a little 
of the moist mass on the point of a lancet, he makes as many punctures in 
the skin as he thinks necessary. These punctures very soon inflame, and 
the resulting pustules may be enlarged at pleasure, by applying a solution 
of tartar emetic by means of a hair-pencil. This i^an seems worth a trial, 
which we have not yet made, because we continue to find the croton-oil 
liniment answer so admirably for the purposes of counter-irritation.* 



Effect qfErffot ofBge in Palsy of tJie Lower EMremities, 
Db Ducbos of Marseilles {Journal de CRnique de Marseille) reports a case of 
palsy of the lower extremities of long standing, in which the eigot of rye was 
productive of much benefit. The patient, at eighteen years of age, had a 
severe fall on his back, which was succeeded by weakness of the lower ex- 
tremities. His Umbs soon recovered their natural strength, and he re- 
mained weU for a year. The history of the case during the next twenty-five 
years is summarily disposed of in these few words : ** An bout de ce temps, 
rechute." The patient was forty-four years of age when he came under Dr 
Ducros* care, and he was then affected with complete palsy of the lower 
extremities along with incontinence of urine. 

At first about 4 grains (25 centigrammes) of the powdered ergot were 
administered in pills ; this quantity, we presimie, was taken at least daily, 
though that is not stated. The dose was progressively increased, so that 
after rather more than six weeks, he had come to take upwards of 20 
grains at once (1.50 gramme). 

At this time the patient presented a remarkable improvement. He 
could now stand firm on his legs, and walk ; he could also control the dis- 
chaige of urine. Soon after it became necessary to dim iniab the dose of 
the ergot, on account of the tingling produced by it in the soles of his feet. 

The use of eigot in diseases of the nervous system has been hitherto 
little attended to, or rather almost entirely neglected. One case, such as 
that just referred to, wiU not go for much, especially of a disease like 
paraplegia, which has sometimes disappeared suddenly without any treat- 
ment — ^most probably because the disease has slowly ceased hj the efforts of 

* Scottish ttnd NmDi of Eng^md Med. Cassette, No. V. 



PATHOLOGY AND PRACTICE OF MEDICINE. 155 

nature, often a consideiahle time before the patient himself discovers that 
he is cured. But in confirmation of the probable good effects of ei^t in 
the above case^ we should notice the sufficiently well known influence of 
f%ot on the nervous system, analogous to the effect of narcotics, marked 
^K giddiness, delirium, and dilatation of the pupil, while we learn horn 
^^le's learned memoir on ergot, that there are oflier cases of paraplegia in 
'^hich it has been found beneficial.* 



PATHOLOGY AND PRACTICE OF MEDICINE. 
Conneaian between Hydrocephalus and Disease of Lungs. M. Mavtbner. 

In 229 dissections, made between the years 1837 and 1842, of children 
who had died of encephalitis and acute hydrocephalus at the Foundling 
Hoflpital of Vienna, M. Mauthner found the following appearances : — In 
172 casea^ serum in ventricles with or without material alteration ; in 123 
casefl^ where the effusion was copious, tubercles occurred in the lungs 43 
times (20 of these with hepatisation) ; hepatisation without tubercles^ 
90 times ; and complete solidification of a part of the lungs in 7 cases : 
hjdrothorax, 14 times; hydropericardium^ 61 times; ascites, 10 times; 
cedema of the lungs, 39 times : so that in 133 cases where there was ef- 
fosion of serum in the ventricles, there were fbnnd in 86 mortal diseases 
of the lungs, besides many affections of the abdominal viscera, among 
which tubercles of the spleen occurred 42 times. 



Inflammation qf Columna CamecB a Cause of Insufficiency of Valves, 

M. Hamerujk of Prague has published some interesting observations on 
inflammation of the muscular substance of the heart, which he believes to 
be £!^uent, and to occur usually in the left ventricle. The anatomical 
charactovs are hyperemia, infiltration with exudation into the cellular 
tisRie and atrophy of the muscular fibre, suppuration, abscess. The mus- 
cular tissue becomes flabby, and when examined with the microscope is 
found to have lost its spiial appearance, become less smooth, and covered 
with little pulverulent bodies. 

IL H. thinks it difficult in some cases to distinguish inflammation from 
&tty degeneration of the heart, and relies chiefly on the microscope and 
the application <^ heat for establishing the diagnosis. The object of the 
paper, and it is an important one, is to show that without any disease of 
the valves themselves, they may be rendered insufficient by inflammatory 
disease of the columns cameee having destroyed the tonicity of these 
minolee, and rendered them incapable of duly performing their function of 
closing the valve. 

Vaccination latent for Three Tears. 
M, Wenwoer of Vienna has published a case where vaccination was 
performed on a child eight months old in July 1887, and did not become de- 
veloped till July 1840, thus remaining latent for three years ! 1 1 

• See Bayle,— Bibliotheque Th^rapeutique, tome iii. p. 648. 



156 PATHOLOGY AND PRACTICE OF MEDICINE. 

Tartar Emetic as a Remedy fir Syphilis, 

M. WiLLEBRAND lias been employing tartar emetic for the treatment of 
syphilis in the Military Hospital at Helsingfors, the capital of Finland. 
Employed in primary syphilis, the sores healed in from 12 to 20 days. It was 
not, however, tried in indurated chancre. Its effects were most strikingly 
beneficial in secondary affections of the throat and scrotum. In thirty cases 
the symptoms disappeared in 11, 12, or 15 days. The tartar emetic was 
usually continued six or eight days after the disappearance of the symptoms. 

When given in the skin affections, S. roseola disappeared in a few dis- 
eases. The squamous class were more unmanageable, lasting from 20 to 
26 days. The inconveniences attending the prolonged use of the remedy 
often required it to be given up before the completion of the cure. 

The tartar emetic was exhibited in doses of half a grain six or eight 
times a-day. The first doses commonly produced vomiting, but tolerance 
was usually established on the second day. To this, however, there were 
exceptions : one case is recorded where the dose could not be raised above 
the eighth of a grain without acting at once on the stomach and bowels. 
[We have observed the most remarkable difference in this respect in ex- 
hibiting tartar emetic pretty extensively for chest affections. We usually 
give it in doses of half a grain every hour, in some cases the first or first 
and second dose provoke vomiting, in other cases it does not occur till the 
third has been swallowed ; sometimes the patient does not vomit at all, 
while in others, again, the remedy provokes vomiting at every dose. In one 
case of a child of two years ol^, §ii. of antimonial wine were taken in doses 
of a tea-spoonful every hour without emesis, while two tea-spoonfuls of the 
same preparation, when swallowed by ourselves, produced severe nausea 
and vomiting]. The general health was also carefully attended to by M. W. 



loduret of Potassium in Saturnine Affections, 

At a late meeting of the Academy of Sciences, MM. Natalis Guillot and 
Melsens called the attention of that body to the favourable results of the 
ioduret of potassium administered in the treatment of saturnine diseases. 
Hitherto they have administered this substance alone, allowing the patients 
to live as usual, when their state admits of it, as regards food. They gra- 
dually increase the dose to 5iss or 3ij a-day. From six to ten ounces of 
the ioduret has appeared to them sufficient to complete the treatment. 
Their object in giving publicity to these facts is, they say, to give rise to 
further experiments on the therapeutic action of the ioduret of potassium in 
these affections. 



MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN. 

Pelvic Inflammation after Parturition, 
In Guy's Hospital Reports for April of this year, there is a conmiunication 
on a subject which is very important to those who take an interest in 
obstetric medicine and surgery. It is by Dr Lever, of whose labours we 
have had occasion to report so favourably in our last number. Dr Lever 
furnishes the results of his experience in nine cases of pelvic abscess occur- 
ring at various periods after parturition ; in one instance, so late as eight 
weeks after this event. Dr Lever considers the inflammation of a chronic 
character, an opinion by no means happily chosen, and which, were it not 



PELVIC INFLAMMATION AFTER PARTURITION. 157 

that we might be considered hypercritical, we could easily refute. These 
cases, though they must have been occasionally met with, have been little 
noticed in our literature since the time of Levret, probably because they 
ahnost always terminate favourably. The young practitioner, however, 
whose mind is often haunted with the consequences of inflammation in the 
puerperal state, ought to feel under considerable obligations to Dr Lever for 
his excellent practical communication. In six of the cases the abscess 
burst per vaginam, in three at either groin ; in one of this number the 
contents were discharged both at the groin and by the rectum ; in one 
there was suppuration at both groins ; in one of the cases the abscess fol- 
lowed an attack of puerperal fever ; and in another of them, phlegmasia 
dolens succeeded to the abscess. In our own practice, we remember one 
case which supervened on uterine hemorrhage, two on puerperal fever, two 
after the use of forceps, one after an easy first labour; and in the last 
instance which occurred to us, an abscess formed at each groin after a first 
labour, which had been easy, and in which there had been no artificial 
interference ; in one of these only did the abscess burst per vaginam, in 
none per rectum ; and all of them happened within a fortnight after 
delivery. Dr Lever does not ofier any decided opinion as to the cause, 
which shows his good sense, since such cases have been observed after easy 
as well as difficult labours — after deliveries |Where there was no inter- 
ference, as well as subsequent to those in which artificial aid had been 
afforded. As, fortunately, post mortem inspections are rare, it would be 
hazardous to state, in decided terms, in what structure the inflanmiatory 
action commences ; but we are certainly disposed to concur in Dr Lever's 
views on this head, by believing that the cellular structure of. the pelvis is 
involved, as also one or more of the uterine appendages — an opinion sup- 
ported by the contents of these abscesses being, in the majority of the cases, 
evacuated external to the peritoneum. 

The most important point for consideration in these cases is the diagnosis. 
We know from experience how readily they may be confounded with other 
and more severe inflammatory affections in the puerperal state. Rigors, 
accelerated pulse, heat of skin, and pelvic uneasiness, are among the pro- 
minent features of these cases ; but it is to be particularly remarked, that 
they are not attended by that anguish and general tenderness of the abdo- 
men, so characteristic of those affections usually denominated puerperal 
fever ; — ^that the uneasiness, though accompanied by a good deal of general 
disturbance, is more local, while the patient is completely alive to every 
thing around her. Sometimes the uterus feels larger than it ought to be 
at a period so distant after parturition as that at which the disease com- 
mences ; but in other instances nothing unusual can be discovered by the 
most careful examination over the pelvic brim. Per vaginam, again, our 
investigations are not, in some cases, more satisfactory. Often, however, 
this canal feels very sensitive, hot, contracted, and very painful ; and the 
patient shrinks during its exploration, complains of great uneasiness at some 
particular point, where, probably, we discover some swelling. Though we 
are not disposed to dispute the value of Dr Simpson's sound in cases of 
uterine disease, unaccompanied by tenderness of that organ, yet we cannot 
concur with Dr Lever in thinking that any sound, except sound sense, can 
be safe when the uterus is in a state of high irritation. We reprobate the 
practice of poking instruments into the uterus when highly excited. 

Although we have admitted that these cases eventually terminate in a 
fevourable way, nevertheless we consider an early distinction of them from 



168 INHALATION OF OXYGEN. 

other more fonxudable affections of the last importance, if it were for no 
other reason than to prevent unnecessary depletion by the lancet, which 
would be certain almost of rendering the system most irritable, and incapa* 
citating a woman for the important duty of nursing. Dr Lever^s manage- 
ment of these cases is very judicious : leeches to tiie pained parts, warm 
fomentations, tepid ablutions of the sexual canal, enemata, and antiphlogistic 
regimen in the acute stage, but a generous diet afterwards, are &e reme* 
dial steps. 



FORENSIC MEDICINE AND MEDICAL POLICE. 
Inhalatum ofOofygen an Antidote to Poisoning with Carbonic Add. 

^ An apothecary was engaged in a confined cellar in the preparation of nitric 
ether from a mixture of alcohol and nitrate of potass : during the process 
a lai^ quantity of carbonic acid and carbonic oxide were given off: his 
assistant, who was suddenly seized with a painful sensation in the head, and 
covered with perspiration, was sent out ; he himself however remained in 
the cellar 15 or 20 minutes longer, and, just as he was in the act of leaving 
it, he fell senseless on the steps. He was immediately brought into a chamber, 
where he lay motionless, with the eyes closed and the face of a pale yellow, 
with the exception of the cheeks, which, together with the lips, tongue, and 
hands, were livid ; the pupils were fixed and somewhat dilated ; all the senses 
had entirely disappeared ; the carotids beat violently, the action of the heart 
was frequent but weak, the pulse scarcely perceptible, and the breathing 
weak and irregular. The cold douche was used without benefit. In order 
to free the lungs and brain from engorgement, blood was drawn from the 
arm ; it was of a chocolate-brown colour, of the consistence of syrup, and very 
quickly coagulated. After this the breathing appeared somewhat more firec^ 
perspiration covered the body ; but the sensibility of the skin seemed in no 
degree increased, for a sinapism which was applied to the breast showed no 
effect upon it. As none of the means employed seemed to be of much use^ 
a quantity of oxygen was prepared, in order by inhalation to oxidise the 
blood, overloaded with carbon, more rapidly than could be done by the 
inhalation of atmospheric air merely. After the patient had been in a 
state of insensibility for an hour and a half, he was made to inhale the 
oxygen for a few minutes. A remarkable reaction followed : the ale of the 
nose dilated, the appearance of the counten^mce improved, the muscles of 
the jaw and mouth began to act when loudly addressed ; there was motion 
of the eyeballs, the breathing became normal, the pulse fuller, the skin 
perspired freely, and the patient seemed to feel the ntustard cataplasm. 
After he had used, in the space of a quarter of an hour, two and a half quarts 
of oxygen, when loudly spoken to he awaked as if from sleep, and att^oopted 
to rise, but his sight had not then as yet returned. After the above state 
had lasted two hours and a half, and after he had slept fi>r half an hour, the 
senses were completely restored, and some blood which accidentally fbwed 
from the arm was again become scarlet. Some of the blood which was 
analyzed yielded 50*8 per cent, of carbon and 7*1 of watery fluid.'* — Cas^x 
Wochemchryt, No. 47, 1843.— It appears to us that cupping should have 
been employed, as that mode of abstracting blood has been found the most 
beneficial in such cases. We may perhaps assume the dark colour of the blood 
as a proof that the diluted carbonic acid enters the lungs, — ^thatin £M;t it acts 
IBS a poison, and not merely as an asphyxiating agent^ by closing the glottis. 



COMPARATIVE WEIGHT AND LENGTH OF FCETUS. 159 



Comparative Weight and Length o/FeUtu bom at the full Time. 

As there are numerous questions which arise on triab for infanticide, &c.y 
where the weight and length of the foetus at hirth is of importance to he 
known, w€ are induced to extract the following recent observations of M. 
Elsaesser of Wurtemheig :— 

In 1600 children he found 
13 weighed from 4 to 5 pounds. 318 weighed from 7 to 8 pounds. 

168 d ... 6 ... SS 8 ... 9 ... 

417 6 ... 7 ... 11 9 ... 10 ... 

The average weight to be deduced from this is 4 lbs. 28 loth (or half 
oances). The lightest child weighed 4 lbs. 23 loth, and the heaviest, 9 lbs. 
30 loth. M. £.'s results differ somew ha t from those of other authors ; for 
example, Mde. Lachappelle met with one child at the full time weighing 
3^ lbs. Qiamaaier, in 1601, found 3 we^hii^ 2 lbs., 31 of 3 lbs., and 97 of 
4 lbs., tiad he also observed others weighing II, 16, and 17| lbs. We 
think, however, with M. E., that these statements of Chaussier ought to be 
received with a due degree tf cautian ; sadh cases certainly present very 
lue exceptions to the general rule. M. £. found that 

llie aven^ weigM of 100 males was 7 lbs. Of loth. 



«.. ... 


,, 


females 




6 


... 21 


... 


Tbe maximum weight 


of the males 




9 


... 30* 


... 


... ... • 


,, 


females 




lot 


... ... 


... 


The minimum we^ht 


of the males 




4 


... 28 


... 


... ... 


.. 


females 




4 


... 19 


... 


Of 260 children 














The length in 11 


was from 15 to 16 inches. 




... ... 


99 


... 


16 .. 


. 17 


... 




... ... 


75 


... 


17 .. 


. 18 


... 




... ... 


14 


... 


18 .. 


. 19 


... 




... ... 


1 


... 


19 .. 


. 20 


••. 




Hie average length 


of 100 males 


was 


17 inches 3^ 


lines. 


... .. 




females 


... 


16 


... 8 


... 



The maximum length of the males among 1000 children 

was 19 inches 17 lines. 

The maximum among the females 19 ... 1 ... 

The mmimum among the males ... 14 ... 15 ... 

The minimum among the females ... 14 ... 9 ... 

There is therefore a difference in length, as well as in weighty in fkvonr 
of the male children. We are glad to observe that M. E. has also directed 
lus attention to the comparative lengths of the supra and infira umbilical 
portions of the body. His observations will be of use in doing away with 
the absurd notion, so confidently put forth in most works on midwifery 
sod medical junsprudenee, that in the ehM bom at the fUQ time tin 
imibilicus is the centra! point of the body. 

In 200 children the length of the suprarumbilical portion of the body was 
In the males 9 inches 2| Ihies. 

females 9 

The length of the infra-umbilical portion was 

In the males 7 inches 9 lines 
... females 7 ... 7 ... 

* In leveral cases. f In one am only. 



160 EDINBURGH MATERNITY HOSPITAL. 

The difference of lengtli between the two portions was 
In the males 1 inch 3-40 lines, 
females 1 ... 3*57 ... 
In one case the infra-nmbilical portion was 3 lines longer than the snpra- 
nmhilical ; in another (one only) they were exactly equal. M. £. has also 
ascertained, that the distance from the ensiform process of the sternum to 
the umbilicus is generally about one inch longer than from the umbilicus 
to the symphysis pubis. The author also concludes from his observations, 
that variations in length are much leas than those in weight, the former 
being : : 16 : 20, but the latter : : 6 : 10.— ITcn/reV Zeitschrift fur die 
Staate Arzneikiindey No. 42, tom. iv.* 



Part IV.— MEDICAL MEMORANDA. 



EDINBURGH MATERNITY HOSPITAL. 

J^'oR some time past the attention of many of our influential citizens and 
medical brethren has been directed toward the establishment of a Maternity 
or Lying-in Hospital. Since the hospital of the late Professor Hamilton 
has ceased to exist, the want of clinical obstetrical instruction on the great 
scale of a Lying-in Hospital is a stain on the medical school of Edinburgh, 
in other respects one of the £rst in Europe ; but when, apart from any ad- 
vantage to our medical school, we consider the object in view solely in a 
philanthropic light, or when we regard the mere motives of humanity which 
liave prompted the attempt to establish such an institution, we are grati- 
fied to know, that after many consultations and much tedious deliberation, 
matters are so far in train that we may hope to have this desirable and much 
wanted institution in early operation. It is already under noble and dis- 
tinguished patronage, and we are assured that the highest in authority in 
these realms will be happy to confer on an institution intended to relieve 
the sufferings of her sex the benefit to be derived from her patronage. It 
will not, like the last, be the hospital of an individual, but it will be the 
hospital of the public — ^to apply for aid will be all the recommendation re- 
quired. A medical staff has already been appointed ; and the selection that 
has been made does the highest credit to the judgment of the directors, and 
gives us the fullest guarantee of their capability and willingness to direct the 
afiairs of the institution In such a manner as will be most conducive to its 
utility. The following gentlemen have been appointed : 

Consulting Physicians — ^Dr William Campbell, Dr Beilby. 

Ordinary Physicians — Professor Simpson, Dr Moir. 

Assistant Medical Officers-^DT Charles Bell, John Niven, Esq., Alexander 

Thomson, Esq., W. S. Carmichael, Esq. 
Consulting Surgeon^Dv Pagan. Ordinary Surgeonr—Alex. Zeigler, Esq. 

• The Wurtemberg pound is equal to 1.0314 English avoirdupois, and the inch 
is equal to nearly *94 of an English inch. 



Printed by OUver & Uoyd, TwMddale Court, High Street, Edinburgh. 



THE 

NORTHERN 

JOURNAL OF MEDICINE. 



No. III.— JULY 1844. 



Part I.--ORIGINAL ARTICLES. 



Cases of rare Malignanb Disease of the Ovary. By J. C. W. 
Lever, M. D., Member of the Royal College of Physicians, 
London ; Assistant Accoucheur at Guy's Hospital, and one of 
the Lecturers on Midwifery at that Institution ; Author of a 
Practical Treatise on Organic Diseases of the Uterus. 

Cask 1. — Mrs F , set. forty-six, the mother of six 

children, the youngest six years of age, consulted me in April 
1843. She stated that, two years previously, she suffered from 
pain in the region of the liver, for which she placed herself 
under the care of a distinguished physician, who ordered 
blisters and various modes of relief, and at last advised her to 
leave London. This she did, and the pain subsided. 

Eighteen months afterwards she perceived, immediately 
above the left groin, a hard moveable swelling of a circular 
form, unattended with pain, and even firm pressure caused but 
little suffering. Its size increased, and it was associated with 
menstrual irregularity, loss of appetite, languor, despondency, 
&c. She again sought the advice of the same physician, who, 
after a very careful examination, pronounced the uterus free from 
disease, but stated that in his opinion the ovary was the seat of 
mischief. The treatment prescribed was simple and palliative, 
but the tumour rapidly enlarged. 

In April 1843 I first saw her. Her countenance was pale 
and anxious, her alse were compressed, her cheeks hollow and 
drawn in, the superficial veins of the body generally were 
very distinct, and she was much emaciated. There was some 
swelling of the left thigh, leg, and foot, which indented when 
pressed by the finger. The abdomen was of irregular form, 
from a tumour wmch occupied the left side, apparently rising 
out of the pelvis. This tumour had a firm but elastic feel ; it 
could be traced into the left loin as high as and under the 
Tibs, and in front it could be detected as high as the stomach, 

X 



162 RARE MALIGNANT DISEASE OF THE OVARY. 

although its superior margin could not be accurately defined ; 
it extended to the right of the mesian line, and on its surface 
there were three other tumours the size of walnuts, but flattened, 
which could be made to roll over the larger tumour very dis- 
tinctly. Although she complained of great pain in the seat of 
the large tumour, yet she did not experience much uneasiness 
when it was pressed upon, but the shghtest examination of the 
smaller growths caused her considerable suffering. 

The hver was enlarged, and pressure over its region caused 
pain ; her bowels were moved daily, and occasionally with her 
motions a sanious fluid was mixed; her urine was clear, and 
she stated that at no time had it been mixed with blood. 
There was considerable irritability of the stomach, the tongue 
was morbidly red, the papillaB elongated; she was restless, 
worn out with pain and loss of sleep, and her pulse was quick, 
small, and irritable. 

She was ordered, — MorphisB acetat. gr, ss., o. n. et p. m. ; with 
sod. sesquicarb. gr. x. ter die in aqua month, virid. The pills 
gave her rehef , the irritability of stomach subsided, but the tumour 
rapidly increased; the lower extremities became enormously 
enlarged from serous infiltration ; this reached to the abdominal 
integuments, and into the abdominal cavity itself a large quantity 
of fluid was effused. In the course of a few days, symptoms 
of effusion into the cavities of the pleurae mamfested them- 
selves ; and, after enduring with heroic fortitude her aggravated 
sufferings, she expired on the morning of July 24. 

The body was examined eighteen hours after death. The 
integuments of the abdomen, upper and lower extremities, 
were glossy, distended, and oedematous. 

Thorax. — (Right side). About sixteen ounces of yellowish 
fluid were effused into the cavity. The posterior surface of the 
middle lobe of the lung was hepatized ; in the apex of the 
upper lobe there were a few scattered tubercles. (Left side). 
Some slight but old adhesions existed in the upper part of the 
cavity, and in it were about eighteen ounces of sanguinolent 
serum. In the apex of the lung, also, there were some crude 
tubercles. The pericardium contained four ounces of hghtish red 
serum. The heart was small, oedematous, flabby, and readily 
lacerable ; its valves were healthy. 

Abdomen. — The liver was large, about twelve lbs. in weight, 
universally infiltrated with tubercles varying in size from that 
of a pea to a small apple. They presented the true cerebriform 
character. The gall-bladder was large, and distended with 
thin greenish bile. The pancreas was large, and firmly fixed ; 
its tissues were infiltrated with fungoid tubercles varying in 
size. The spleen was healthy; the stomach small, but free 
from disease ; the small intestmes healthy, the large intestines 
small and empty. The mesenteric and meso-colic glands were 



RARE MALIGNANT DISEASE OF THE OV AHY. 163 

enlarged, and affected with the cerebriform disease. The right 
kidney was pale and granular. The uterus was healthy. 
The right ovary had on its anterior aspect one tubercle about 
the size of a small shot. 

The tumour which had attracted attention during life had 
emanated from the left ovary ; it had surrounded and com- 
pressed the left kidney, which was small, pale, and granular, 
and had ascended behind the transverse colon as high as the 
inferior curvature of the stomach. On making a section, it 
presented the characters of true cerebriform cancer. The 
moveable tumours that could be distinctly felt on the surface were 
developments of the disease in the omentum. 

The head was not examined. 

Case 2. — Miss T. , aet. thirty-six, of dark sallow complex- 
ion, whose occupation in life has been that of a governess, was 
seen by me on the evening of January 19, 1844. She was much 
exhausted by a journey of seventjr miles ; and prescribing some 
moderate stimulant, the investigation of her case was adjourned 
nntil the following day. For five months she complained of 
difficulty in passing her urine, and a constant desire to micturate, 
attended with pains during the passage of the water, as well as 
occasional heavy pain above the pubes and in the left iliac region. 
During the first two months of her illness her catamenia appeared 
at the proper time, but for the last three periods they have been 
suppressed. The medicines prescribed by her attendant failing 
to relieve her, he instituted a vaginal examination, and discovered 
a tumour which he pronounced " ovarian." 

The patient was thin and sallow, her conjunctiva blanched, 
her pulse small and quick, the action of the heart was readily 
excited, the respiration regular and normal. The abdomen ex- 
ternally was flat, the parietes very thin ; and in the left and 
inferior part, extending firom the left iliac region to above the 
pubes, a sohd, hard, oblong tumour could be lelt, about the size 
of a duck's egg, irregular on its surface, and very moveable, 
obeying the impulse of the hand, as well as changing its situa- 
tion according to the position of the body. Per vagincmt this 
tumour could very readily be felt at the upper and left side of the 
uterus, so that its thickness could easily be estimated by one 
finder in the vagina and another on the surface of the abdomen. 
When the tumour was depressed in the pelvis by the hand placed 
upon the abdomen, the uterus as well as the tumour protruded 
into the vagina ; but still the uterus could be moved independently 
of the tumour itself, showing their want of connexion, or rather 
that, if attached, the connexion was not intimate. The os uteri 
was small, and the attempt to introduce the uterine bougie caus- 
ing much pain, its employment as a means of diagnosis was de- 
sisted from. The catheter passed into the bladder found this 



164 RARE MALIGNANT DISEASE OF THE OVARY, 

yiscus small, and, as the abdominal parietes were very thin, the 
pomt of the instrument could be felt anterior to and below the 
tumour. The urine was muddy when drawn off ; it became 
perfectly clear on boiling. Per rectum the uterus could be felt 
rather large, as also the tumour pressing upon the bowel and 
diminishing its calibre. (The bowels were usually constipated, 
and she had suffered from hemorrhoids.) She complained of 
great numbness and pain in the left thigh and leg, which she 
stated was occasionally swollen, but when examined it was not 
found to be larger than the right. The pain and numbness were 
increased by lying on the left side. The treatment prescribed 
consisted in the administration of sedatives to allay pain, stimu- 
lating tonics, and a due supply of bland nutriment ; but she be- 
came more and more exhausted, and died about mid-day on the 
30th January. 

Permission was given to inspect the abdomen, which was done 
about twenty-six hours after death. It was tense from tympan- 
itic distention, and indistinct fluctuation could be readily felt. 
On opening the parietes, about one pint and a half of straw- 
coloured serum wa§ found in the cavity ; there were no traces of 
either old or recent peritonitis. At tne lower part of the abdo- 
men, on the left side, rising from the pelvis, a tumour came into 
view, of a yellowish-gray colour, its surface nodular and irregu- 
lar, tolerably firm in its texture, and very moveable. It was 
anterior to the left Fallopian tube, but not connected with it ; 
the left ovary was lost in the development of the tumour. On 
making a section, numerous light-coloured lines could be seen, 
showing its cystiform character ; and the section in some places 
presented a lemon-yellow colour, in others it gave a reddish ap- 
pearance. When the section was made, a considerable quantity 
of thin yellowish fluid was poured out. Several of the nodules 
on the surface of the tumour were examined ; some were solid, 
but the exterior membrane or cyst was of a lighter colour than 
the interior ; others consisted of a capsule, more or less thick, 
containing fluid varying in density and colour from a light lemon 
to a dark brown, and from the fluidity of serum to the thickness 
of treacle. When the uterus was drawn upwards and forwards 
from the cavity of the pelvis, a similar tumour on the right side 
came into view, globular in form, but with an irregular surface, 
similar to the tumour on the left side. It also had no connexion 
with the Fallopian tube ; but the ovary itself was lost in the 
structure of the tumour. The uterus presented no abnormal ap- 
pearance ; it was large for a virgin organ, and some of the muci- 
parous glands of the cervix were prominent. 

The stomach, large and small intestines, were distended with 
flatus, pale in colour, and their coats remarkably thin. The 
liver was pale, wrinkled by tighulacing, a7id throughout affected 
with encephaloid cancer. The spleen was small ; the pancreas 



CHRONIC DISEASES OF THE STOMACH. 165 

healthy ; the kidneys large, flabby, and pale. The mesenteric 
and meso-colic glands were all enlarged ; some were soft, as if from 
tubercular degeneration; others were firm, presenting a yellowish- 
ted colour on diyision ; whilst a third class, when a section was 
made, showed a surface firm in some spots, soft and cerebriform 
in others. 

Permission was not given to inspect the other cavities. 

A microscopical examination of the morbid structure was made 
by Mr Birkett, demonstrator of anatomy at Guy's Hospital, and he 
reports : — " The mass was firm but easily lacerable, containing 
opaque and somewhat translucent material, apparently cystiform. 
It consisted of single and double nucleated cells, with bicaudate 
cells. A considerable quantity of fibre was present." 



Practical Observations on some of the Chronic Diseases of the 
Stomach, generally known by the symptomatic Nam^es of Car^ 
diaigia, Gastrodynia, Pyrosis, Neuralgia, cj-c. By William 
Strange, M.D., M.R.C.S. Edin., Surgeon to the Ashton- 
under-Lyne Dispensary. 

Chronic disorders of the stomach and other digestive organs, 
arising either in consequence of existing organic disease, or of 
what IS often erroneously called functional derangement, present 
themselves so commonly to the observation of the medical prac- 
titioner, and so much has been written upon their pathology and 
treatment, that it would be almost impossible to advance any 
thing new or striking upon the subject. Dr Abercrombie, with 
many other authors of modern date, as Andral, Barras, Johnson, 
Paris, and Wilson PhiUp, have given us a collection of cases 
and observations which may be said to include amongst them 
every phase and character which this protean disease can assume. 

Neither is there a greater paucity of remedies — ^prophylactic, 
dietetic, and curative — ^than the immense variety of dyspeptic 
affections would lead us to wish for. Scarcely an article of the 
materia medica but has either been sanctioned by long usage, 
or been recommended by the sanguine eulogiums of individual 
practitioners, as serviceable in some one or all of these affections. 
We should omit many were we to enumerate all the vegetable 
bitters and tonics, purgatives and emetics ; the alkalies, alkaline 
earths, metallic oxydes, salts of iron, copper, zinc, bismuth, and 
arsenic; mineral acids and waters; galvanism, hydropathy, 
homoeopathy, &c. 

It would be merely idle, therefore, to occupy space devoted 
to the advantage of the profession with such a subject, were it 
not that, notwithstanding this richness of detail, and vast amount 
of detached and isolated observations, there is a great want of 



166 CHRONIC DISEASES OF THE STOMACH. 

connexion between the therapeutic and the pathological know- 
ledge of gastric diseases preyalent in the profession, and which 
leaves a hiatus in the chain of observation most embarrassing in 
practice. It is having felt the want of appropriation of the 
remedy to the particular character of the disease, which first 
led me to pay particular attention to this subject ; and I feel 
confident that success in the daily treatment of these most com- 
mon ailments can only be arrived at by careful observation of 
the different varieties of dyspeptic disorder, coupled with a 
patient and extensive application of therapeutic agents and thera- 
peutic knowledge, based upon sound physiolo^caJ theories. The 
young practitioner, until he has made a classification (at least in 
his own mind) of gastric disorders, will be constantly puzzled in 
his choice of remedies, and the more so, as a thorough knowledge 
of their therapeutic actions is only to be obtained by long obser- 
vation and repeated failure and aisappointment. 

To those practising in the midst of a dense population in 
large towns, particularly if they be mercantile or manufacturing, 
stomach disorders are every day presenting themselves. The 
observations I am about to make are based upon personal 
attention to more than 1600 cases, of more or less serious 
character, occurring in a period of a few years. 

Most of the works on indigestion which have issued from 
the press of late years are samy deficient in what I have above 
stated to be so necessary in practice, viz. a classification of the 
varieties of the disease, and a correct definition of the several 
pathological conditions upon which they depend. Without 
something of this kind the treatment of gastric disorders must 
be mere empiricism. If a proper division, founded upon the 
essentially distinct morbid conditions in the coats or fluids of the 
stomach had formerly been made, the now exploded doctrine of 
"gastrite chronique" would not have been applied to all the 
derangements of the digestive apparatus ; nor such fatal practice 
as the indiscriminate use of tlje lancet, leeching, counter-irrita- 
tion, and mercury, have been resorted to, — ^means which, in five 
cases out of six, I conceive to be not only useless but highly 
prejudicial. 

Dr Abercrombie, however, in his excellent little work on the 
pathology of the stomach, and Andral, Barras, and others, have 
many observations of great value, showing the error of referring 
all painful affections of the stomach to a chronic inflammation ; 
and the first author has thrown out some useful hints for a 
classification of these disorders, founded chiefly upon the nature 
of the pain and the period of its attack. He urges the necessity 
of a classification of the varieties, in order to a satisfactory ap- 
plication of the therapeutic and dietetic means of remedy. In 
attempting to separate the different varieties of gastric disorder, 
I shall foUow as much as possible a natural method, both as to 



CHRONIC DISEASES OF THE STOMACH. X67 

the severity of the symptoms and the succession of the attack, 
when, as often happens, seyeral yarieties, each increasing in 
intensity, follow each other in a regular train of symptoms, 
constituting what may be called the most aggrayatea form of 
dyspepsia. I shall confine myself on the present occasion to 
remarks on those affections which are not necessarily dependent 
upon organic disease or cacoplastic action, but are generally 
(although erroneously) ascribed to functional derangement of the 
stomach. Such a mode of viewing the following class of 
disorders is, however, at best but doubtful ; and I feel convinced 
that the more advances we make towards a correct knowledge 
of the nature of these affections, the more we shall find them to 
be dependent upon structural or organic, although not permanent, 
changes. An appreciable alteration in the structure and appear- 
ance of the mucous membrane, of the muscular coat, or of the 
vessels and nerves of the stomach, such as thickening of the 
mucous membrane, pale and flabby state of the muscular sub- 
stance, varicose state of the veins, &c., are as much appreciable 
organic changes as are inflammation, ulceration, or scirrhus. 
Without denying the existence of any form of chronic (or 
fonctional) derangement of the stomach which may not be 
allocaited to some one of the following divisions, and allowing 
that they may and often do run into each other in such a 
manner as to make it difficult to say to what patholo^cal 
conditions the symptoms are to be attributed, the attentive 
practitioner will have no difficulty in distinguishing the follovring 
principal varieties, all of which have several forms. 

1^9 Dilatation, torpor, or, to speak with more precision, atony 
ofthest(»nach. 

2dy Atony with morbid irritability. 

Sd, Acute irritation. 

4thy Neuralgia, generally accompanied with pyrosis, to which 
the name of gastralgia might perhaps be more properly restricted. 

5thy Chronic gastritis. 

Each of the above varieties I have many times been able to 
distinguish as a distinct and separate attack, although two or 
more of them are often met with coexisting, and pyrosis is in 
some measure met with in all of them. Generally, however, 
the order of succession, where an individual presents several 
varieties at once, is atony, morbid irritation, or else neuralgia, 
and then chronic gastritis ; the persistence of which last may 
remduce any of the former varieties. 

l«f. Atony of the stomach. — This kind of gastric affection, so 
common amongst the crowded population of manufacturing towns, 
presents the following symptoms and physical signs : — The 
tongne is large, flat, and mbby, filling the whole width of the 
mouth, its surface almost uniformly pale and without scurf, pre- 
senting the appearance of boiled veal or muscular fibre which 
^ been macerated in cold water ; the face pale and flaccid. 



168 CHRONIC DISEASES OF THE STOMACH. 

corresponding remarkably with the tongue; the epigastrium 
distended, not painful, but uneasy on pressure ; the abdomen in 
women often pendulous and flabby, sometimes hard and tender ; 
the pulse is generally unaffected, or it is weak and small. 

Patients affected with this form of disease complain that they 
have no appetite, or that they crave for things which are to 
them indigestible. Immediately after even a hght meal, they 
experience a feeling of distention which compels them to loosen 
their dress, and maS:es muscular exertion exceedingly distressing. 
There is not often any very acute pain in the region of the 
stomach or along any part of the digestive canal ; but some* 
times to the sense of fulness succeeds a constriction about the 
lower part of the epigastrium, accompanied by eructations of 
gas sometimes mixed with acidity. There is flatulence, with 
irregularity of the bowels, a general state of costiveness being 
occasionally interrupted by a painful diarrhoea. A feeling of 
constriction, with pain extending through to the back, coming 
on two or three hours after meals, may be owing, as is supposed 
by Dr Abercrombie, to irritation created in the duodenum by the 
passage of insufficiently digested food into that bowel ; and I 
have remarked that this pain very frequently coexists with a 
relaxed state of the bowels and painful motions. On the whole, 
however, a feeling of acute pain coming on periodically some 
hours after a meal is much more frequently met with in another 
well marked form of gastric disorder, viz. where the tongue ex- 
hibits a degree of redness round the edges, with furred centre ; 
and where there is pain on pressing the epigasti'ium, denoting 
an irritable state of the mucous and muscular coats of the 
stomach. In consequence of the uneasiness and pain which are 
occasioned by all heavy articles of diet, persons affected with 
an atonic state of the stomach generally live upon slops, such as 
tea, milk, gruel, porridge, &c., substances which from their bulk 
tend to increase the previous distention, easily run into chemical 
changes, and are destitute of those stimulant properties which 
are necessary to arouse the torpid or diminished contractility 
of the stomach. Although opportunities of dissection are but 
seldom afforded us when the disease has not proceeded beyond 
this the least severe form, yet post-mortem exammations have often 
exhibited a pale, flabby, and distended state of the coats of the 
stomach, which has coexisted with the foregoing symptoms ; 
and this, with our knowledge of the action of the stomach in the 
process of digestion, together with analogous affections of other 
hollow organs, warrant the conclusion, that a want of tonic con- 
tractile power in the muscular substance of the stomach is the 
real essence of this disorder. The flabby and pale tongue, the 
distended abdomen, with a sluggish state of the bowels, and pale 
skin, all denote a corresponding deficiency of vital power in all 
the organs of the body. 

Accordingly, we are not surprised to find this variety of dys- 



CHRONIC DISEASES OF THE STOMACH. 169 

pcpsia extensively prevalent amongst the inhabitants of lar^o 
towns, particularly if the population be employed chiefly in 
crowded workshops and manufactories. The want of ventilation, 
the dust, smell, and uniform warmth of cotton factories especially, 
but principally the absence of the stimulant and invigoratii^ 
properties of fresh cold air, are, in my opinion, the very predis- 
posing causes most certain to induce this affection. Sedentary 
habits, with insufficiency of out-door exercise, too, undoubtedly 
produce the same condition of the digestive apparatus in the 
middle and upper classes of society. 

Such being one of the commonest derangements of the stomach 
for which the practitioner is called upon to prescribe, it is essential 
to make choice of those remedies which possess at once a tonio 
and stimulating, but not sedative and enervating property. 
Were he, instead of doing so, to haye recourse to antiphlogistic 
treatment, bleeding and counter-irritation, the patient would go 
from bad to worse, and a most intractable irritability of the 
stomach would be brought on, leading in all probability to 
organic and incurable disease. With the view of reducing the 
imtation, if any, and of gently stimulating the stomach, I haye 
for a length of time mainly depended upon one substance, viz. 
the oxide of bismuth, which has also been highly extolled by 
Dr Paris and other authorities. When cases to which it is ap- 
plicable are selected, I believe that not one in ten cases will 
occur in which much benefit will not be procured from its use. 
The manner in which I prescribe it is as follows : — 
R. Bismuth, trisnitrat. . 5j- 

MorphiflB muriat. . . gr. ss. — -j. 

AcacisB muciL . • . ^ij* 

Syrup, zingiber., 

Tinct. car(mm. com. ana, . 3iij. 

Infus. cascarill. . §v. M. 

5j. ter die. 
This formula retains its appearance for a length of time ; the 
mucilage suspending the bismuth in such a manner as to give 
to the mixture the consistence of cream. In pyrosis taken at 
the period of attack, and in that form of gastrodynia previously 
described, taken half an hour after meals, it immediately assuages 
the pam and promotes digestion. Whether the bismuth acts aa 
an astringent, or as a tonic and stimulant, I know not ; but in 
those cases particularly which will be hereafter described, 
where there is considerable derangement of the duodenum, this 
medicine acts like a charm. 

Undoubtedly much benefit may be often obtained from the 
vegetable bitters with alkalies, and from the preparations of 
quinine and iron, particularly the sulphate and ammoniacal 
citrate, and from mineral waters. The good effect, however, of 
direct tonics I have always found most evident after the more 

Y 



170 CHRONIC DISEASES OF THE STOMACH. 

distressing symptoms have been removed by a perseverance for 
a short time in the above formula. 

All kinds of fermented and spirituous liquors, as they debili- 
tate as well as stimulate, are injurious in this affection. Purga- 
tives must not be resorted to for the relief of the costiveness 
which so often accompanies this form of dyspepsia, as bv over- 
exciting they afterwards debilitate the intestines. Gentle laxa- 
tives with tonics, such as small doses of aloes or colocynth with 
sulphate of iron, as recommended bv Dr Abercrombie, or with 
sulphate of zinc, are the most beneficial. 

2d, Atonic morbid irritability of the stomach. — ^Although 
a simple state of deficiency in the vital power or tonic contractiUty 
of the coats of the stomach often exists alone and uncomplicat^ 
with any other derangement of the digestive apparatus, yet it 
appears that when timt state has existed for some length of 
time, symptoms of morbid irritation set in, and either supersede 
or obscure the earlier symptoms. Consequently I look upon 
this second form of dyspepsia as the natural consequence of a 
long continuance of the former atonic variety. Nevertheless 
there are numerous cases to be met with, in which there have 
been induced symptoms which indicate the existence of more or 
less acute morbid irritation of the mucous membrane lining the 
stomach and duodenum, without there having previously existed 
any trouble in the digestion which could lead us to suspect any 
derangement of the tonicity or innervation of those organs. 
Indigestible articles of food, affections of the mind, pressure 
upon the stomach, and bad living, are common causes of morbid 
irritation of the gastric mucous membrane. 

The symptoms indicating this affection differ considerably 
from those characteristic of mere want of tone. The tongue 
is generally slightly red at the tip or round the edges ; there is 
a thin whitish fur all over the centre which cannot be scraped 
off; a sense of heat in the throat, oesophagus, and sometimes in 
the stomach. The sleep is often disturbed, and muscular efforts 
are weakened. The appetite is always uncertain in this affection, 
following the remissions and exacerbations of the attacks. 
There is a general desire for savoury and solid food, although 
this almost invariably aggravates the symptoms. There is 
pain in the stomach durmg the whole time the food remains 
there, which is sometimes relieved by vomiting coining on from 
half an hour to three or four hours after a meal. Substances 
in small quantity are seldom returned. In some cases there is 
a sense of weight only at the stomach, until about two hours 
after taking food, when a sense of pain and constriction ensue, 
which lasts frequently until relieved by a relaxed but unsatis- 
factory motion. In these cases it has been no doubt rightly 
supposed that the irritable stomach pushes onwards the partially 
digested food into the duodenum, whence it is either forced 
back by vomiting, or passes out of the bowels, after giving 



CHRONIC DISEASES OF THE STOMACH. 171 

pam in its whole course, in a partially relaxed and often scalding 
motion. This morbid irritation of the stomach is sometimes 
accompanied by a degree of pyrosis, but not by any means in 
a constant manner. The regurgitations are more frequently 
composed of the mucus of the stomach mixed with acidity, gas, 
and the aroma of the food. We meet with pure cases of 

Eyrosis, where a large quantity of a transparent water, called 
J the patents water-tomes, or in other instances of a glairy al- 
buminous fluid, is pretty regularly ejected from the stomach after 
a paroxysm of severe neuralgic pain ; more constantly in another 
form of gastric disorder, viz. that in which the pam is not so 
constantly excited by taking food into the stomach, but comes on 
in a periodical manner at certain hours of the day, or after an 
interval of one or two days, or a longer period. This form I 
shall afterwards advert to under the designation of neuralgic 
irritation of the stomach, or gastralgia. 

The medical treatment of chronic morbid irritation of the sto^ 
mach will depend very much upon the previous duration of the 
disease, its complication with other morbid conditions, and upon 
the general state of the patient's constitution. When the dis- 
order has not arrived at any very troublesome height, a similar 
treatment to that recommended n)r atony of the stomach will be. 
found to answer very well. In more exaggerated cases, how- 
ever, and especially if there be much pain and heat at the epi- 
gastrium, it will be well to begin with moderate counter-irritation, 
as a blister, two or three mustard poultices, or the ung. antim. 
tart. All drastic purgatives, particularly mercurial ones, should 
be avoided, as they mcrease the irritation. The oxide of bis- 
muth, with infusion of rhubarb and magnesia, will be found to 
answer the double purpose of maintaining a steady action upon 
the bowels, and of correctiuj^ the acidity and heat of the stomach. 
The following is a good formula : 

R Bismuth trisnitrat. . . 3j. 

Magnes. carb. ... Sss. 

Tinct. hyoscyami . . 5iij- 

Infus. rhei; .... gviii. M. 
One ounce of this mixture to be taken three or four times a-day* 
After the more acute symptoms have been reduced, the mixture 
of bismuth with gentle stmmlants and tonics, as prescribed for 
the atonic state, will answer well ; and, finally, we may have 
recourse to quinine, iron, zinc, and other direct tonics. 

Should there be much acidity with regurgitation some time 
after taking food, accompanied with a costive and unsatisfactory 
state of the bowels, the following pill taken regularly after the 
principal meal will be found very useful : 

& Aloes in pulv. . . gr. iss. 
Ferri sulph. . . • gr- ij; 
Sapon. dur. . . gr. vi. M. 

Div. in pill. ij. simul sumend. 



172 ON PERlTYPHLtTIS. 

The soap is a great addition to- the aloes and iron pill in com- 
mon use, as it unites chemically with the free acid of the stomach. 
I must reserve the dietetic treatment of these two varieties of 
gastric disorder for a future occasion. 

(To be eontinuedJ) 
Ashtoh-ukdea-Ltke. 



On Perityphlitis, or Inflammation of the Cellular Tissue adja- 
cent to the Coscum. By William Seller, M. D., &c., one 
of the Physicians to the Royal Dispensary, Edinburgh. 

It is now fifteen or twenty years since the attention of the 
medical profession in France and Germany was first drawn to 
the not unfrequent occurrence of inflammatory turgescence ad- 
jacent to the coBCum, and yet the subject has hardly been adverted 
to in the most recent systematic works published m this country. 
The only work indeed of this description in which I have met 
with even a cursory notice of this inflammation, under the name 
of Pericoecal Inflammation, is Copland's Medical Dictionary.* 
No doubt Mr Syme seems to point to this kind of inflammation 
in a few lines devoted to iliac abscess.f But that term is not 
specific enough to denote the disease which I am going to de- 
scribe ; and, as he speaks of the treatment by an early aperture, 
and regards the disease as of most frequent occurrence after 
parturition, I am inclined to think that the cases on which he 
founds must have been of a different character from those which 
come strictly under the head of Perityphlitis or pericoecal in- 
flammation. Cases are recorded of this form of inflammation 
which show the evil effects of rash interference with the lancet ;{ 
and Dupuytren expressly says, that in his experience males are 
much more liable to it, under all circumstances, than feinales.§ 

The name Perityphlitis is used by Dr Albers in a memoir on 
coecal inflammation, and, though somewhat pedantic, I have 
adopted it for want of a better. || My attention was first drawn 
to tnis disease several years ago ; and the following account is 
founded on cases which I have myself seen, as well as on a care- 
ful study of the detached memoirs which have been published on 
the subject. 

The disease in question is of an acute though insidious charac- 
ter, has its seat external to the peritoneum, in textures of a cellu- 

* See Coecum. 

t Principles of Surgery, p. 328. 

$ Dupuytren, Le9on8 Orales de Clinique Chirurgicale, tome iii. pp. 343, 345. 

§ Ibid. p. 336. 

II Histoire de rinflammation du Caecum (Typhlite), par J. Fried. Herm. Albers, 
Froiesseur de M^dedne A 1* University de Bonn. Traduit par J. B. Pign6; Ency. 
dographie des Sciences M^dicales, tome x. (1839), p. 181. 



ON PERITYPHLITIS. 173 

lar structure^ and, unless neglected at first, is more prone to re* 
solution than to the formation of pus ; when suppuration does 
occur, the pus is almost invariably evacuated by the rectum. 

Tenderness on pressure, hardness, dulness on percussion, and 
circumscribed swelling of the abdomen, adjacent to the anterior 
part of the crest of the right ilium, while the integuments move 
freely over the tumour, are the prominent and least variable 
symptoms of this disease. In extent, the part so affected varies 
considerably. But when, as happens sometimes, the swelling 
reaches across the abdomen towards the linea alba, or upwards 
obliquely towards the umbihcus, the disease should be suspected 
of having lost its original singleness of character, and of having 
passed into an inflammation of the peritoneum, or even perhaps 
of the coats of the bowels. 

Pain of the upper part of the thigh in front, increased on 
motion, is either not a constant symptom, or is so trivial in the 
majority of cases as to have escaped the notice of most observers. 
In the cases which I have seen it was present, though not re- 
markably severe ; and in that with the particulars of which I 
am best acquainted, it was the pain rismg upwards from the 
thigh which first led to the discovery of the real seat of the dis- 
ease. Probably the function of the bowels is never altogether 
unaffected; yet the degree in which intestinal disturbance is 
present has a wide range. In the case first referred to, of which 
a short report will be given hereafter, with the exception of coHc 
pains, rather severe for two or three hours, the bowels were 
positively unaffected in their functions ; there was not the slight- 
est accumulation of feculent matter, and there was nothing that 
could be called constipation. On the contrary, in a case which 
I saw under Dr J. Duncan's care last winter, also to be noticed 
hereafter, the obstruction of the bowels could not be overcome 
by any means, and the event was fatal, apparently in connexion 
with this cause. In the major part of the cases reported by the 
original authorities on this subject — Husson and Dance, as well 
as by Meniere, and in most of the additional cases given in Du- 
puytoren's *' Logons Orales de Clinique Chirurgicale" — ^though 
all of these are not simple cases of this affection, constipation 
and colic pains were present until the remission of the disease.* 
In a few mstances diarrhoea preceded the attack. 

Nausea, vomiting, and anorexia are sometimes among the 
symptoms, but are by no means essential features of the disease. 

Symptomatic fever is not usually very well developed ; in the 
simpler cases the pulse is natural or but shghtly accelerated ; in 

* Husson et Dance, M^moire sur quelques Engorgements Inflammatoires dans 
la Fosse Iliaque Droite : Repertoire G^n^ral de Clinique Chinirgicale, tome iv. p. 74. 
Paris, 1827. Meniere, Sur des Tumeurs Phlegmoneuses dans la Fosse Iliaque Droite : 
ArdiiYcs Oentfrales de M^decine, tome xvii. pp. 188, 513. Ao6t, 1828. Dupuy- 
tren, Leyons Orales, tome iii. p. 330, Des Abces de la Fosse Iliaque Droite. 



174 ON PEKITYPHLITIS. 

the severer, sharp, hard, or jarrmg, not often small or oppressed, 
as in inflammations of the intestines. 

The disease is apt to come on insidiously; the colic pains 
which most commonly usher it in may last only for a few hours, 
or may recur at intervals for several weeks, before the swelling 
appears. The disease is of uncertain duration — chiefly, however, 
owing to the unequal periods over which the precursory symp- 
toms are spread. When the precursory period is short, the 
disease uncomplicated, and the treatment appropriate, a cure 
maybe looked for in ten or twelve days from the commencement. 

A degree of induration, however, occasionally remains, which, 
though not dissipated for some time, gives but Uttle inconvenience. 
There is observed in some patients a disposition to the recur- 
rence of the disease for a longer or shorter period after it has 
subsided. In one person it occxu'red three times within a period 
of sixteen months. But this is not the usual course of the dis- 
ease. In the experience of Dupuytren, it is stated to have been 
ascertained, that after having suffered from this inflammation, 
one person remained in perfect health for sixteen years, another 
for nine years, and a third for eight years.* It would be sur- 
prising if a malady of this nature should not be sometimes com- 
plicated with permanent abdominal disease; but the complete 
and rapid recovery in most cases, even under unfavourable cir- 
cumstances, should preclude the idea thrown out by some autho- 
rities that it is generally connected in its origin with mucous 
inflammation in the adjacent parts of the intestine.t 

The unfavourable terminations of this disease are suppuration 
and extension of the inflammation to the peritoneal lining of the 
abdomen, and even to the coats of the intestines, the latter ter- 
mination being a supposition rendered sufficiently probable, but 
not yet confirmed by adequate evidence. 

In the " Logons Orales " of Dupuytren, the disease is termed 
abscess, and all the cases detailed terminated by suppuration ; 
which might lead one to infer that resolution is a less common 
result than suppuration. The contrary of this is proved by 
reference to the other memoirs on the subject, with the excep- 
tion of that of Albers, who erroneously represents suppuration 
as the most frequent termination ; but the following passage 
from the " Le§ons Orales " shows that Dupuytren did not regard 
suppuration as the most frequent termination : " Dans un grand 
nombre de cas, elles se termment par resolution ; dans quelques 
circonstances, par ime abondante suppuration ; quelquefois enfin 
elles sent le point de depart d'une inflammation qui s'etend h 
toute la surface du peritoine."J In the memoirs referred to 

• Rdperloire, tome iv. p. 86. f Dupuytren, Le9ons Orales, tome Hi. p. 336. 
$ lb. tome iii. p. 331. 



ON PERITYPHLITIS. 175 

there is no attempt to give the statistics of this disease ; yet, not- 
withstanding that seyere and fatal cases are commonly chosen 
for report, we find three cases of resolution recorded by Dance 
and Husson, and seven by Meniere. 

But even the termination by suppuration, as in the case of 
abscess of the pelvis after parturition, is for the most part unat- 
tended with serious consequences.* To the pelvic inflammation 
after parturition, the disease under consideration has manifestly 
a considerable analogy. Yet active treatment in the early stage 
is plainly more essential than in the pelvic inflammation ; for 
the tendency to suppuration seems to be exactly proportioned 
in this disease to the neglect of free evacuations of blood, even 
by venesection, on the first onset of the inflammation. 

In a case in which twenty-two days were allowed to elapse 
from the first attack of pain in the right iliac fossa, and fourteen 
days from the discovery of swelling in the same place, before 
treatment was resorted to, pus was evacuated by stool, and at 
the same time the tumour in the ccecal region disappeared, and 
the patient recovered.f 

In another case, a young man, aet. twenty-six, was admitted 
into the Hotel Dieu, who had suffered for several days be- 
fore from dull pain, tension, and swelling in the right iliac fossa. 
There were colic pains at intervals, and the bowels were consti- 
pated ; the pulse was unaffected. Six days thereafter, during 
which a few leeches were applied, and some inefficient refriger- 
ant and emollient treatment practised, acute pains arose, spread- 
ing over the abdomen ; next day there was great tenderness on 
pressure, and the pulse was frequent, small, and constricted. 
Venesection was resorted to, and numerous leeches were succes- 
sively applied. In seven days from the occurrence of acute pain 
the symptoms remitted, and m five days more obscure fluctuation 
was discovered in the right iliac fossa. On the following day 
a discharge of pus commenced from the rectum, which contmued 
for six <Eiys, while the swelling by degrees subsided. The 
patient was finally dismissed quite cured.J 

In this case the swelling in the right iliac fossa, which was 

Eesent some days even before he was admitted into the Hotel 
ien, appears to have been overlooked at first, or held of trifling 
consequence ; and it is probable that a somewhat greater activity 
of treatment in the early stage would have prevented at once 
the peritonitis which, beyond question, arose six days after his 
reception, and the suppuration into which the original disease 



Three cases besides are reported by Husson and Dance, in 
which suppuration occurred, and yet recovery took place, the 

* See Periscope of June Number, p. 156. 

t Meniere, Archiyes Gtfn. de Mtfd., tome xvii. p. 200. 

j Husson et Dance, Repertoire, tome iv. p. 80. 



176 ON PERITYPHLITIS. 

pus being in every instance evacuated by the rectum ; and in 
these three cases active treatment was either not practised at 
all, or not till a late period of the disease.* And in Meniere's 
memoir there are five cases of recovery reported after the dis- 
charge of pus by stool, on nearly all of which the same observa- 
tions as to the delay of proper treatment may be made.f In 
Dupuytren's " Logons Orales" a similar case is recorded, in 
which recovery took place after the evacuation of pus bv stool ; 
the patient was received into the Hotel Dieu on the nfteenth 
day of his illness, and pus was observed in his stools on the day 
of his reception ; leeches had been applied and venesection had 
been once practised before he came to the hospital, but at what 
period is not stated. 

The same work contains a case cited from Ouvrard, which 
shows that tumours of this kind should not be unadvisedly 
opened. A man of twenty-eight years of age was affected with 
vomiting for six days, and then a phlegmonous swelling was 
discovered in the region of the coecum. At the end of three 
weeks pus was passed by stool. Some swelling remained" (as is 
not uncommon), and the surgeon, wishing to evacuate its contents, 
opened the abdomen without finding an abscess, and penetrated 
into the coecum. The wound was closed. The health quickly 
declined, fever, looseness, and general emaciation followed. At 
the end of six months, after a journey in a rude carriage, an 
abscess pointed below the cicatrice, and soon opened spontane- 
ously, discharging pus and feculent matter. By means of ap- 
propriate applications, compression, rest, and a strict regimen, a 
cure was accomplished after the lapse of eight months.^ 

It seems certain that the pus formed in perityphlitic inflam- 
mation sometimes, though very rarely, penetrates through the 
abdominal wall ; yet it is not to be inferred at once that every 
discharge of pus through an external aperture in this region 
arises from such an inflammation, since pus formed at a distance, 
or what is termed a congestive abscess, may be evacuated in 
this region. No case of this mode of evacuation, however, is 
reported in the two principal memoirs on this disease,— either in 
that by Husson and Dance, which contains eight cases, or in 
that by Meniere, which contains thirteen cases. The following 
case, reported in the " Le§ons Orales," seems to be unequivocally 
an instance of the termination of perityphlitic inflammation in an 
external opening, since pus was first discharged by stool. A 
young man of twenty-four years of age was treated at the Orleans 
Hospital for a phlegmonous tumour in the right iliac region, 
which he had at first neglected. He passed pus by stool, and 
his health was partially restored. He then went to Paris, where 

* Husson et Dance, Rtfpertoire, tome iv. p. 80. 

t Meniere, Archives Guncrales, tome xvii. p. 200-207. J lb., pp. 343, 344. 



ON PBRITYPHUTIS. 177 

his complaint increased, the swelling enlarged, and abscesses 
opened in the right ihac region of a fistulous nature, through 
wiiidi pus and feculent matters were discharged. After a 
tedious illness of several months, accompanied with cough, 
diarrhoea, emaciation, and CBdema of the lower extremities, and 
after being several times on the point of sinking, he recovered.* 

In the cases which prove fatal, no evacuation of pus either by 
the rectum or by external opening for the most part takes place ; 
but a copious deposit of pus is found on dissection almost uni- 
formly, I think, as far as the reported cases show, along with 
marks of extension of the inflammation to the peritoneum. A 
case of this kind is reported by Meniere. A young man, twenty- 
four years of age, subject to colic pains and purging, was re- 
ceived into the Hotel Dieu ten or twelve .days after he had 
been attacked with a dull pain in the right iliac region. No 
treatment had been practised. The tumour in the right iliac 
region was not very prominent, but very painful on pressure. 
The constitutional symptoms were rather severe. Leeches were 
applied on three successive dajrs with percei)tible relief. On 
the evening of the fourth day violent colic pains came on, the 
stools were frequent, and there was great tenderness on pressure 
all over the abdomen. The fever was intense, the patient com- 
plained much, was excessively restless, and much changed in 
aspect. The swelling had extended, and its border was no 
longer discoverable. On this day venesection was practised, and 
forty leeches put on. The next day thirty leeches were ap- 
plied, all without effect, and death took place on the 8th day. 
On dissection, general peritonitis was found involving the omen- 
torn and peritoneal coat of the sniall intestines. The ccecum was 
detached with the greatest ease from the iliac fossa. The 
cellular tissue lining that region was charged with a yellow 
almost concrete pus. This ii^tration ascended to the level of 
the right kidney, and extended into the pelvis around the 
bladder and rectum, and traces of it were met with even on the 
left side. The cellular layer which unites the peritoneal coat of 
the intestines to their muscular coat was equally softened, and 
on seizing a convolution of the ileum, it was easy to strip off its 
outer coat. 

The case before referred to, which I saw under Dr J. 
Duncan's care last winter, had a similar course, though, as an 
inspection of the body was not permitted, we are left to con- 
jecture as to the exact state of the disease at the time of death. 
The patient was a female servant of twenty years of age. In 
the beginning of December 1843 she was seized with pretty 
severe pain m the right iliac region, attended with vomiting. 
Next day, a medical man, regarding the case as one of colic, pre- 

• Lejons 0;ales, to.ne iv. pp. 342, 343. 



178 ON PERITYPHLITIS. 

scribed assafoetida pills, which were taken without relief, and he 
did not return. On the fourth day Dr Duncan saw her. She 
then complained very much of pain in the right iliac fossa. 
The vomiting had ceased for the last twelve hours. Pressure 
over the seat of the pain gave considerable uneasiness, and a 
slight degree of fulness was perceptible. The bowels had not 
been moved fi*om the morning of the first attack. Pulse 100, 
rather full ; skin rather warm ; tongue pretty clean. 

As the case seemed to be one of inflainma.tion around the 
ccDcum, twenty-five ounces of blood were drawn from the arm, 
with the effect of affording some relief. Two grains of calomel 
with half a grain of opium were ordered to be taken every three 
hours. The next day the fulness was much more perceptible ; 
a tumour in short could be distinctly defined in the region of the 
coecum, and traced up into the lumbar region, while there was no 

feneral distention of the abdomen. " Some evacuation of the 
owels from an enema. Pulse 100, of good strength; skin 
warm ; restless and uneasy, but thinks the pain is not quite so 
severe." The use of calomel and opium was continued, and 
twenty-four leeches wqre ordered to the affected part, and 
fomentations to be kept up. " Leeches acted freely, but without 
affording relief.*' Next day there was some increase of the 
tumour, which was still well defined, though some distention of 
the abdomen had arisen. '' Pulse, 112 ; tongue clean and moist ; 
no vomiting ; some scanty evacuation from mjection." Twelve 
leeches and the continuation of the fomentations, together with 
the calomel and opium, were ordered. The next day the tumour 
was still further enlarged, and, notwithstanding an increased 
distention of the abdomen, could still be distinctly traced out. 
From this time the patient gradually got worse and worse. 
The tumour appeared to increase, but its definition was lost in 
the general distention of the abdomen, which progressively aug- 
mented. The vomiting returned. The bowels became obstinately 
obstructed, the pulse small and feeble, the tongue dry. The 
skin became covered with profuse perspiration, hiccup came' 
on, and she died on the eleventh day from the commencement of 
the attack. 

The signs of peritonitis in this case are by no means unequi- 
vocal. The obstinacy of the constipation points perhaps to the 
gut itself having become the seat of inflammation. It seems 
certain that inflammation affects the coecum itself; yet how far 
that disease is hable to be combined with inflammation of the 
adjacent cellular tissue does not yet appear. The dissections 
hitherto pubhshed hardly throw sufiftcient light on this point. 
Albers, to whose memoir I have already referred, sa^s that 
Puchelt* (to whom he ascribes the first notice of this cusease), 

* I have not seen Puchelt^s memoir; Heidelb. Klinische Annalen, vol. viii., 
cah. 4 ; nor Posthuma's, De Intestini Cceci ejusque Processus Vermicularis Paiholo- 
gia; Groning. 1836. 



ON PERITYPHLITIS. 179 

as well as Posthuma and other pathologists, have confounded 
cases of perityphlitis with typhlitis or inflammation of the 
ccecom itself. But though Albers has given a very elaborate 
account of this disease, I have drawn little from him, and am 
less disposed to rely implicitly on his diagnostics, because the 
cases on which he founds are plainly less simple in their original 
character and course than those described by the French patho- 
logists before cited. It is nubiifest that one of the greatest 
ol^tacles to the progress of pathology is the complication of the 
cases which most usually prove fatid, of the dissection of which 
almost exclusively minute accounts are obtained. For it is sel- 
dom in our power to unravel a series of morbid alterations, when 
any part of it is still unreduced to a general law, or to deter- 
mine what changes existed before the last attack came on, — 
what are the immediate results of that attack, — what are strictly 
coincident compUcations ; — and of these, what are casual or for- 
tuitous, — what are consecutive, or arise connectively with the 
general tendency of the original disease. That Dr Duncan's 
case was a complicated case, it seems impossible to doubt ; but on 
the nature of the complication it is less easy to pronounce, or 
whether the serious compUcations preceded the attack of peri- 
typhlitis or followed it; and whether fortuitously or connec- 
tively^ in the absence of a dissection, it is impossible even to 
oomectore on probable grounds. 

On the views of Albers, this case should perhaps be pro- 
nomiced a normal case of perityphUtis, for it does not in any 
respect agree with the character which he lays down as that of 
typhlitis, while it does correspond in a great measure with the 
cases which he gives as illustrating the coui;pe of perityphlitis. 
And he plainly represents the disease as more apt to involve the 
peritoneum, and more disposed to terminate fatally, even when 
the pus has passed off by the rectum, than the French patholo- 
gists, on whose cases I have mainly relied in the foregoing 
account of perityphlitis. 

There are but two cases reported in the memoir of Albers, 
and as both somewhat resemble the two cases just given, 
this is the proper place to refer to them. One of these is the 
case of a cluld eight years of age, in whom this disease termi- 
nated a highly acute attack, marked by alternate constipation 
and diarrhoea. In the history of the case nothing is said of the 
motion of the thigh being affected ; yet after death tiie psoas was 
found red and softened, there was abundant suppuration adja- 
cent to the coecum, but no perforation of its coats ; the peritoni- 
tis was confined to one patch close to the coecum ; the mucous 
membrane, however, of the coecum was red and easily detached.* 

The other case is that of a butler, twenty-nine years of age, 

• Albers, p. 1«2. 



i 



180 QN PERITYPHLITIS. 

who had been m good health till the period of the influenza in 
1835, when he began to suflfer from periodical pains of the 
abdomen, and constipation. He was adyised to try the effect of 
cupping and of a cold bath, after which the pain became dimi- 
nished in intensity, but more constant, and concentrated in the 
right iliac region, while diarrhcea alternated with constipation. 
This state of things continued five days, during which he waa 
engaged in his usual avocations. Then he became affected with 
alternate chills and heat, and the pain in the right iliac region 
grew very severe, and there were occasional colic pains. A 
swelling now arose in the right iliac region, and soon after blood 
and pus appeared in the stools. Death took place on the third 
day after the aggravation of his complaints. On dissection, pus 
was found behind the coecum, extending upwards to the kidney, 
and downwards to the brim of the pelvis. There was an open- 
ing in the coBcum the size of a small coin, and the pus was still 
trickUng into the gut. The appendix vermiformis was hard and 
thick, the right kidney was red and softened. The iliacus in- 
ternus was indurated, and its cellular tissue was destroyed by 
the pus. Both these cases are plainly far from simple. 

The cases hitherto referred to illustrate the several less 
favourable terminations of this disease, namely, suppuration 
with discharge of pus by stool, the same with discharge by an 
external aperture, and suppuration with superadded peritonitis, 
or some other serious complication. The case which 1 am going 
to report shows the most frequent course of the disease, when 
it is uncomplicated, and proper treatment is early resorted to. 
This case, of the particulars of which an abstract will suffice, 
well illustrates the insidious mode in which this iilflammation 
makes its attack. 

The patient was a medical man about forty years of age. 
Towards the end of July 1840, being to all appearance in per- 
fect health at the time, he awoke in the middle of the night 
with severe griping pain, which continued for two or th^ee 
hours, and then passed off with a slight evacuation of the 
bowels. He remained in bed for a part of the day without 
uneasiness, and on getting up towards the afternoon felt nothing 
but a sense of weariness, and of weight and slight tenderness 
over the abdomen, as if the bowels were not sufficiently sup- 
ported by the parietes. No new symptom arose for the next 
two days ; he took a moderate quantity of light food, and slept 
at nights as usual. He believed he was recovering his usual 
health and strength under rest and restricted diet. On the 
evening of the third day, when getting into bed, he noticed a 
sUght pain in the fore-part of Sie right thigh, which in the 
course of the night he found to commence in the right iliac 
region. Next morning^ there was considerable pain and tender- 
ness on pressure in that region ; and on exammation a distinct 



J 



ON PERITYPHLITIS. 181 

hard circumscribed swelling, giving a dull sound on percussion, 
and tender to the touch, was discovered there. The bowels 
were free ; the constitutional symptoms were not well marked, 
but the pulse was rather frequent, and unnaturally harsh and 
jarriuff. Twenty leeches were applied to the swelling with 
partial relief, and in the afternoon blood was drawn from the 
arm to sixteen ounces. At night, a pill of calomel and opium. 
Next day the symptoms had abated, but were not removed. 
Venesection was again practised to the same extent, and twenty 
leeches applied to the swelling ; the pill was continued. Ne^t 
day the (usease seemed effectually got under ; two days after, 
twenty leeches, on account of some stinging pains in the part, 
were again applied, with complete relief. There was no longer 
pain or tenderness in the part, but a slight hardness could 
still be felt on careful examination, which entirely disappeared 
after a trivial inunction with mercurial ointment kept up for a 
few days. The state of the bowels gave no trouble after the 
first morning ; and ten days after the commencement of the 
attack, the patient waBted out quite well. Once or twice in 
the course of the following winter some threatening of a return 
occurred, which disappeared under rest and light diet ; and 
since that time he has enjoyed uninterrupted* good health. 
Drs Henderson and Skae concurred in the treatment of this 
case. Dr Alison also saw the patient, but not till the character- 
istic marks of the disease had almost disappeared. 

The pathological seat of the affection which we have been 
considering seems beyond doubt to be in the cellular tissue 
between the fascia of the iliacus intemus and the coats of the 
coecum. And this peculiar seat explains why the pus, when 
produced, so unifonnly passes into the coecum itself. The iliac 
fascia, though somewhat variable in character, is for the most 
part a strong fibrous membrane. Its extent and connexions 
form, so long as it is free from disease, an impenetrable barrier 
to the progress of pus outwards. And when we remember 
that about one-third part of the circumference of the coecum is 
uncovered by peritoneum, and that the uncovered part is in 
contact with loose cellular tissue interposed between the iliac 
fascia and itself, we shall no longer feel any difficulties in un- 
derstanding the chief peculiarities of pericoecal inflammation. 
The pus is confined on every side by the close adherence of 
the peritoneum to tlie cavity which it fines. The alternative is, 
on the one hand, that pus so confined, almost in a sac, should 
penetrate through the posterior wall of the coecum, which is 
but making its way through a thin partition to a mucous open 
cavity, or, on the other, that it should penetrate through the 
substance of the iliac fascia, or ascend into the right meso-colon 
bjr separating its lamime, or, detaching the peritoneum from the 
ihac fascia, where it adheres close to it, should make its way 



182 WATER-BRASH. 

into the pelvis. Cases may be instanced, I think, in which 
each of the consequences under the latter alternative has occurred, 
yet very rarely by comparison, and not probably till the in- 
flammation unchecked had extended beyond its original seat and 
destroyed the substance of the fascia, or weakened the cohesion 
between the laminsB of the meso-colon, or that between the 
peritoneum and the subjacent substance, so that less resistance 
was offered to its progress between the laminae of the meso- 
colon, and beneath the peritoneum in €very direction, than 
through the coats of the coecum. 

Edikbuboh, 23 Nelson Street, 12/A June 1844. 



On ike Occurrence of Sarcina Ventriculi ahng with Acetic^ Lactic^ and Car- 
bonic Adds in Water-Brash, By Geoboe Wilson, M. D., Lecturer on 
Chemistry, Edinburgh. 

The object of the following communication is to direct the attention of 
pathologists to some curious phenomena accompanying certain forms of 
> morbid digestion in the human subject. Of these, the most remarkable is 
the appearance of a microscopic cryptogamic plant (^Sarcina Ventriculi), 
and of acetic, lactic, and carbonic acids, in a liquid ejected from the 
stomach. 

The first case in which these were found occurred to Mr Goodsir, and 
was published by him in the Edlnbuigh Medical and Surgical Journal for 
April 1842.* Since that period a case has occurred in the practice of Mr 
Benjamin Bell of Edinburgh, who allowed Mr Goodsir and myself to 
examine the matter ejected by his patient, in which the same organism 
and acids were detected ; and Mr Busk of the Dreadnought hospital ship, 
Greenwich, has published the history of three cases, where the sarcina pre- 
sented itself, but no analysis was made of the fluids in which it appeared. 

Five cases of the sarcina haying thus offered themselves in so short an 
interval, and without any particular search being made for it, it cannot be 
doubted that the development of this organism will be found no uncom- 
mon accompaniment of certain derangements of the digestive functions. 
With a view to direct the attention of medical men to the subject, I have 
drawn up the following account of the more important particulars of the 
cases already met with, along with some observations on the manner in 
which the chemical and microscopical phenomena are related to each other, 
and to the state of the system which attends their manifestation. I am 
indebted to Mr Groodsir for much information on the subject, and for many 
of the suggestions which appear in the following paper. 

The first case occurred in the person of a gentleman aged nineteen, who 
had been suffering for four months from what he believed to be water- 
brash. He stated, ^^that it attacked him on awakening in the morning 
with a feeling of distention of the stomach ; that without any effort of 



• History of a Case in which a Fluid periodically ejected from the Stomach 
contained Vegetable Organisms of an undescribed form, by John Goodsir ; with a 
Chemical Analysis of the Fluid, by George Wilson, M. D. 



WATER-BRASH. 183 

vomiting, a quantity of fluid, varying in volume from two- thirds to a 
whole washhand basinful, passed up from his stomach ; that after this he 
was quite relieved, and experienced no further inconvenience till the 
evening of the same day, when, without decided distention, sounds as of a 
fluid boiling or bubbling, and proceeding from the region of his stomach, 
were perceptible to himself, and to those around him ; that he slept well 
enough, but was generally attacked next morning." The fluid ejected by 
this patient " smelt like fermenting worts, with a &int acid odour. It 
appeared, after having stood for a few hours, moderately transparent, and 
of a light brown colour. It deposited in the bottom of the basin a quantity 
of a ropy matter of a granular appearance ; and on the surface was a mass 
of froth like the head of a pot of porter." 

On examining the fluid with the microscope, the sarcina was at once 
detected, and was found to present the following characters.* In every 
instance the oi^ganisms presented themselves in the form of square or 
slightly oblong transparent plates, of a pale yellow or brown colour, and 
varying in size from the 800th to the 1000th of an inch. They were made 
up of cells, the walls of which appeared rigid, and could be perceived passing 
from one flat surfiice to another as dissepiments. These dissepiments, as 
well as the transparent spaces, were from compression of contiguity recti- 
linear, and all the angles right angles ; but the bounding cells bulged 
somewhat irregularly on the edges of the organism by reason of the 
freedom from pressure. These circumstances gave the whole oi^nism the 
appearance of a woolpack, or of a soft bundle bound with cord, crossing it 
four times at right angles, and at equal distances. From these very striking 
peculiarities of form, Mr Goodsir has proposed for it the generic name of 

SABCmA.t 

On examining the ejected fluid, it was found to possess the following 
characters. It was thick and viscid ; on standing, it deposited a large 
quantity of ropy matter mixed with portions of undigested food, and when 
filtered through paper, had a pale brownish yellow colour, and was quite 
transparent. It still contained much am'mal matter in solution, becoming 
opaque and flocculent when boiled, and giving a very copious precipitate 
with infusion of galls. It also precipitated nitrate of silver densely, and 
when evaporated to dryness, and exposed to a full red heat in a platina 
crucible, left an ash containing much chloride of sodium. It reddened 
litmus powerfully, and efiervesced sharply with alkaline carbonates. It 
contmued strongly acid after being twice distilled, and did not precipitate 
nitrate of silver, but retained the sour smell, which could now be recognised 
as identical with that of vinegar. On . neutralizing the twice distilled fluid 
with lime>water, and evaporating to dryness, a salt was obtained, which, on 
^vug decomposed in a tube-retort with sulphuric acid, yielded a volatile 
odorous add, readily identified by several tests with the acetic. 

It was found by several trials, that on an average, an ounce of the liquid 
neutralized 04 gr. of carbonate of potass ; a quart (32 oz.) would therefore 
neutralize 12-8 gr., which correspond to 9 gr. of the hydrated (crystallizable) 
acetic add, HO-f-C*H'0'. The liquid remaining in the retort con- 
tinued to redden litmus powerfully, after all the acetic acid had been dis- 

• The reader is referred to the Edmburgh Medical and Surgical Journal for 
April 1842 for a more minute description of the sardna, and a detailed account of 
the chemical analysis of the liquid containing it. 

t Sardna J a pack or woolpack. The only spedes is named Sarcina VentricitU, 



184 WATER-BRASH. 

tilled from it. This was traced in part to the presence of a small quantity 
of free muriatic acid ; but it was cliiefly owing to the existence in the liquid 
of a considemble proportion of lactic acid. 

The most remarkable feature of this case, in a chemical point of view, was 
the largo quantity of acetic acid found. Although we have no account of 
the proportion of tliis acid discovered in the healthy gastric juice, or chyme, 
by those who maintain its presence there, it is certain tliat the quantity must 
be very small. Prout overlooked the presence of an oi'ganic acid alto^ther, 
and Gmelin, the great advocate of its existenco, found only traces of it. But 
the quantity of liquid ejected at once by the patient often amounted to more 
tlian two quarts, which would contain 18 grains of acetic acid. The liquid 
otherwise was not particularly examined as to salts or animal matter. 

Mr Bell's patient was a girl aged thirteen, who had suffered at intervals 
for several years from derangement of the digestive oigans. At the period 
when her case came before us, she was stated by Mr Bell to be '* subject 
after her meals, particularly dinner, to enormous distention of the abdomen, 
accompanied by a guigling noise and fetid eructations.'' 

From this state she was relieved by vomiting ; the matter ejected con- 
sisting *^ of a thinnish moderately transparent fluid, with a thicker and more 
tenacious portion like gruel at the bottom of the vessel. It was sometimes 
covered on the surface by a mass of frothy matter, and generally there were 
substances floating in it like undigested articles of food." 

In this ejected matter Mr Groodsir found the sarcina in great abnndance, 
and not distinguishable in appearance from the individuals obtained from 
his own patient. 

Only one specimen of the liquid from Mr Bell's patient was procured for 
chemical examination ; and circumstances over which I had no control 
prevented this being so complete as could have been wished. In general 
appearance it resembled the liquid ejected by Mr Goodsir's patient, but it 
had a paler colour, was less viscid, and less frothy. It reddened litmus 
powerfully, and precipitated nitrate of silver ; a property it owed to the 
presence of chlorides, for no free hydrochloric acid could be detected. A 
portion filtered and evaporated on the water-bath continued to redden 
litmus after prolonged exposure to a temperature of 212°, owing to the 
presence of an acid, believed, for reasotfi stated in the previous paper, to be 
the lactic. Another portion, subjected to a double distillation, yielded a 
colourless liquid, which was not troubled by nitrate of silver, biit was found, 
when examined by the method formerly described, to contain free acetic 
acid. In chemicad characters, therefore, it corresponded to the liquid from . 
the first patient. 

An additional point, however, was ascertained, and that of some import- 
ance. When the liquid from the first case was imder examination, its 
frothy appearance fully satisfied me that it contained a gas in solution, 
which was likely from other circumstinces to be carbonic acid. Experi- 
ments accordingly were made, by warming the liquid in a flask fumkhed 
with a bent tube dipping into lime-water ; and the latter was found to be 
copiously precipitated. But no mention was made of these trials in the 
former paper, because the method followed was objectionable ; since, though 
carbonic acid was manifestly evolved in large quantity, it was quite possible 
that it had resulted from the action of heat on a complex solution of organic 
product?, and had not pre-existed ready formed. With the liquid, how- 
ever, from Mr Bell's case, I ascertained the presence of a dissolved gas, by 
a method which seems in itself unexceptionable. Chemists have long been 



WATER-BRASH. 185 

aware of the fact, that one gas passed through a solution of another, will 
displace it> whatever their comparative solubilities he ; so that hydrogen or 
nitrogen, for example, will liberate carbonic acid, and dissolve in its place. 
Magnns has made a beautifal application of this law to the detection of 
carbonic acid in blood, and I followed his method in seeking for the same 
sabstance in the stomach liquid. A series of Wolfe's bottles was arranged 
80 that hydrogen gas evolved from the usual matenale in the first should 
pass in the second through a strong solution of caustic potass, to free it firom 
any carbonic acid it might contain ; in the third, through lime-water, to 
certify its freedom fivm this gas ; in the fourth, through the stomach-liquid, 
to dii^lace whatever gas it contained ; and in the fifth, through lime-water 
a second time, to show if the displaced gas were carbonic acid or contained it. 
On making tiie experiment, it was found that the current of gas which 
passed through the first lime-water without troubling it, on reaching the 
aecond, threw down an abundant precipitate of caihonate of lime.* 

This experiment proves unequivocally the presence of frree carbonic acid 
in the liquid ejected by the second patient ; and I feel certain that the car- 
bonic add was generated in the stomach, for the liquid was fitythy at the 
moment of its disduuge ; and Mr Bell speaks of the distention of tiie belly 
as ^accompanied by a guigling noise and fetid eructations^" which doubt- 
lesB proceeded, from the evolution of this and other gases. 

I have no hesitation in extending these conclusions to the first case ; for 
the liquid from Mr Goodsir^s patient was more frothy than that from Mr 
Bell's, and it gave off carbonic acid when dightly raised in temperature. 
The patient also, in his account of his sensations, mentioned that ** sounds 
as of a fluid boiling or bubbling, and proceeding from the region of his 
stomadh, were perceptible to himself and to those around him." It is quite 
possible that small quantities of other gases (carbureted or sulphureted 
hydrogen) may have accompanied the carbonic acid ; but it was impossible 
in the circumstances to ascertain this point. 

The liquids^ then, from both these patients, contained, besides undigested 
food and unexamined salts and animal matter, much acetic, lactic, and car- 
bonic add, and in one of the cases a small quantity of muriatic acid. A 
little carbonic add has been found along with other gases in the stomachs 
of criminals executed soon after taking food ;f so that this gas may be in- 
cluded among the products of normal d^i;e8tk>n. But the quantity found 
has always been small ; and in the few cases where it has been possible to 

* The gases contained In a mineral water may be separated by simply heating it, 
and TeoeiTing them over mercury^ But this method can seldom be applied to or- 
ganic liqnids, from the decomposing action of heat on their constituents ; and the 
air-pump has generally been employed to. extract the elastic fluids dissolved in them. 
The conflicting nature, however, of the statements concerning the presence of car- 
bonie add in venoua blood, before the publication of the researches of Magnus, ahowa 
the uncertainty attending the employment of this instrument, when the liquid under 
cia mtn a f ion is visdd, and the quantity of gaa in solution is not very great. Magnus 
states (FoggendorTs Annalen, bd. 40, § 683, quoted in Wagner*a Physiology, p. 
377}} that " under the air-pump the gases of the blood do not begin to escape until 
the column of mercury has sunk under an inch in height,** so that only instrumenta 
of good construction can be employed for experiments of this kind. The method 
by displacement, on the other hand, requires neither an expensive nor a very delicate 
apparatus, and may often aflbrd valuable information concerning the gaaea in the secret 
tioDs and circulating fluida of plants and animals. 

t Liebig*8 Animal Chemistry. 

2a 



186 WATER-BRASH. 

watch the progress of digestion ifk Hying animals, no disengagement of gas 
has been ohserved,* nor is chyme at all frothy ; and in artificial digestion, 
whether performed with gastric juice from a living animal, or with an 
acidulated infusion of pepsine, no evolution of gas has been seen ;t so that 
it is quite oertain that tlie carbonic acid which accompanied the sarcina m 
these cases was in quantity abnormal. 

The same remark applies to the acetic and lactic acids. The names of 
various chemists were quoted in the published account of the first case, as 
representing them as normal constituents of the gastric juice or chyme. 
Their presence in these fluids is denied on the other hand by some of onr 
latest observers^ and many will hesitate to decide on this question, till a 
series of extended researches leave no doubt on the subject. I feel it un- 
necessary, however, to urge a dedsion on a point which will be decisively 
settled in a short period by the inquiries at present in progress. In the 
mean while, all will acknowledge that these acids were abnormal in quan- 
tUy^ and Uiis admission will suffice for our present purpose. 

The first case in which the sarcina was detected by Mr Busk, was that of 
a young man who had sustained rupture of the diaphragm. He had pre- 
viously been in robust health, and survived the injury eight days, during 
which he rejected every thing he swallowed. Besides the ingeista, he 
vomited " a very laige quantity of a peculiar looking brown fluid, 
amounting in the coarse of twenty-four hours to several pints.*' In this 
fluid the sarcina was found. 

The second case was that of a young man, previously in robust health, 
who had sustained fracture of the spine and other injuries. ** About twelve 
hours after the occurrence of the injury he vomited once, and once only, 
«nd the matters rejected conasted of a small quantity of brownish fluid 
mixed with food. The brown colour, as in the former case, was found to 
depend upon the pres^ice of coloured flakes, composed for the greater part 
of the so-called sarcina." 

** The third case was that of a boy, aged about fifteen, who was afi^ed 
with disease of the hip-joint, under whkh he had long laboured, and by 
which he had been much reduced. A short time before his death he was 
jseized witli acute pleurisy, which was attended with frequent vomiting ; 
and in the matter thus rejected, and consisting of little more than mucus, 
were observed many brownish flakes, which were found to be composed 
principally of the sarcina." j: 

In none of these cases was any analysis made as to the chemical character 
of the ejected matter, so that the following remarks must be considered in 
the mean while as applying solely to the first two cases. 

Before attempting any explanation of the nature of this curious disease, 
and the connexion between the chemical phenomena and the development 
of the sarcina, it is necessary to notice that the ejected liquid must have 
consisted partly of secretions from the stomach, partly of products of diges- 
tion, ♦. e, of altered food. It is impossible to state accurately how much 
waa contributed from each of these sources ; but, speaking generally, we 
may say that the bulk of the liquid was secreted by the stomach, while 
the acids were derived from the food, and the animal matter was supplied 
by both. 

• Beaumont^s Experiments and Observations on Gastric Juice. 
t MUller and Schwann in M filler's Physiology, p. 692. 

X For a particular description of these cases, and Mr Busk's views concerning 
tlie sarcina, see Microscopical Jpumal for 1842, p. 321. 



WATER-BRASH. 187 

In the particular account of the tot case, reference was made to the 
similarity between the ejected matter and a fermenting liquid. It was 
impossible indeed not to be struck with its resemblance, not only in general 
characters, but even in specific products, to a vegetable juice undergoing tlie 
lactic fermentation,, in which carbonic acid and other gases are produced 
along with lactic acid and a viscous gummy substance. The sarcina, too, 
might be considered aa the analogue of the microscopic plants which are 
found to accompany the fermentation of infusion of malt and the juices df 
different fruits. For these reasons, and for others which aiv stated more 
fully in the succeeding pages, I was led from the first, along with Mr 
Goodsir, to regard this disease as resulting in great part from the food nof 
dergoing withLi the stomach a peculiar fermentation ; and on a particular 
consideration it appeared that three different views might be entertained 
concerning it. 

1. The disease might be regarded as depending on a simple or spontaneous 
fennentation of the food, t. e. a fermentation resulting fr^rn one of its ooa>- 
fitituents acting as a ferment to certain of the others^ and converting them 
into the acids described. 

2. The sarcina might be considered as the cawa morbi, and true ejusitani 
of the chemical changes in the food, according to the views of fermentation 
entertained by certain continental (^wervers. 

8. The stomach might be looked upon as secreting or furnishing the 
ferment, and the sarcina as an accompaniment only of the fermentation 
excited. 

The last view appears in all respects the most probable ; a f«w words will 
suffice regarding the first two. 

Several affections of the stomach might be referred to, aa fiivouring the 
opinion that a spontaneous fermentation of the food had ocecured in this 
disease. '* It is well known," observes Xaebig, '* that in many graminivor- 
ous animals, when the digestive organs have been overioaded with £resh 
juicy vegetables, these substances undergo in the stomach the same decom- 
position as they would at the same temperature out of the body. They 
pass into fermentation and putrefaction, whereby so great a quantity of 
carbonic acid gaa and of inflammable air is gener^ed, that these organs are 
enormously distended, sometimes even to bursting." Affections of this kind 
are most common in ruminating quadrupeds^ and occur in them in the fiirst 
and second stomachs, before true digestion has begun. They are on this 
account not strictly comparable witib demngements oi digestion occurring 
in the single stomach of a non-ruminant animal. But in the human sub. 
ject analogous cases occur» resulting from the drinking of half-fermented 
wines. The author already quoted refers to *^ the &tal accidents which so 
frequently occur in wl^oie countries from the drinking of what is called 

%ther-white wine This poisonous wine is wine still in a 

state of fermentation, which is inoreaaed by the heat of the stomachy" and 
the amount of carbonic acid is so great as to cause asphyxia by reaching 
thelungs^ 

These cases certainly i^ow that the stomach has not the power of invari- 
ably arresting the fermentation of substances introduced into, it ; nor even 
of preventing its development, where the food is prone to suffer this change. 
Nor does it seem improbable that some cases of morbid digestion may depend 
on an inaction or atony of the stomach, permitting the food to decompose or 
ferment spontaneously. But such a view is inapplicable to the cases before 
us, for the stomach was not passive, but morbidly active, as the quantity of 



188 WATER-BRASH. 

liquid it secreted showed ; and the rapidity with which the food (consisfci '■ng 
of bread, potatoes, and meat) was converted into the seyeial adds, ^^9i^^.as 
much too great to be explicable on the supposition of spontaneous fermeKirfc.^^ 
tion« For these reasons it seems necessary to seek for a ferment out of -^^ne 
food. The other hypotheses are framed to meet this necessity, and may^ 'Km 
contended for on quite independent grounds. 

The second hypothesis, which represents the sarcina as occasioning -ft^'Siie 
fermentation, is at least interesting in relation to these cases, since it was -^lie 
anticipation of some organism being present which led to its discoY^sc-;^. 
Schwann and Cagnard Latour first showed that the fermentation of infusi.<:»:x» 
of malt by yeast, and the spontaneous fermentation of grape-juice and ap;E>l^ 
juice into idcohol and carbonic acid, are attended by the development of s 
microscopic cryptogamic plant, to which the name of Scuxskaromycea or Bxm.^3C^^ 
fungus has been given. And some physiologists have represented th»-^^«» 
fungi as the true cause of such fermentations, — as nourished, in short, ^^y 
the sugar which they excrete as alcohol and carbonic acid.*" 

But before such a conclusion was drawn, it should have been shown tl=»-** 
sugar cannot be fermented into alcohol and carbonic acid without the d^"*^*" 
lopment of these fungi, which has not been done. It seems certain enoi:^.^^ 
that the vinous fermentation of malt and of fruit juices is always aocc^^*^" 
panied by the appearance of the saccharomyces. But these liquids confc-^^"^^^ 
azotised matter besides sugar, and it has not been shown that the fungi a^^^*^ 
more closely related to the latter than to the former. The well-known 03^»>^ 
that the whole sugar is converted into alcohol and carbonic acid, while -tf^ Vie 
frmgi increase in size and numbers, seems enough to show that they m. "■^*^ 
derive their nourishment from the non-saccharine constituents of the liqiB-^^- ^ 
in which they appear. Before the opposite conclusion is drawxi^ it sho w ^* -^^ 
be shown that when a solution of pure grape or milk-sugar has the ^ ' 
fermentation induced in it by the addition of decomposing animal mati^-* 
these frmgi appear, which hitherto has not been done. There is still ro<^ - 
therefore, for doubting if the saccharomyces are so much as constant < 
comitants of the fermentation of pure sugar. And even if it could be sho^^^jj** 
that the appearance of these fungi during fermentation was invariable, -^ * 
would renudn highly improbable that they were more than concomitan*^-* 
For the chemist can refer to many decompositions identical in nature wii>^^ 
fermentation, where no organism of any kind appears ; and the chemicsa^ 
forces which suffice alone to effect great changes cannot be supposed to \q3& 
their efficacy because cryptogamic plants are developed, so that we should 
conceive them to be supplanted by certain inexplicable and improbable 
powers supposed to reside in these organisms. For these reasons, and for 
others which I need not detail, I discard this hypothesis as untenable, and 
refrise to the sarcina the offi^^e of decomposing the food in an abnormal way. 

The third hypothesis represents the stomach as supplying the ferment or 
substance which decomposes the food into the acids found. 

To make my views on this subject clear, I must premise a few obsenra- 
tions on the nature of healthy digestion. According to all recent re^ 
searches, the performance 6f this frmction is dependent on the presence in 
the stomach of two difft^rent substances, — the one, frree muriatic acid, the 
other, an animal matter, to which the name ofpepHne has been given. An 

* For fuller information on this subject, see Meyen's Report on the Progress of 
Vegetable Physiology for 1839, p. 37. Lehmann Taschcnbuch der Chemie (1842), 
p. 979. Liebig*s Chemistry applied to Agriculture, p. 380. Annalen der Phar« 
xnacie, band 29, s. 93 and 100. 



' WATER-BRASH. 189 

infiisioD of this pepsine has no solvent action on hard albumen or other 
alimentaiy matters ; but its addition, even in minute quantity, confers this 
property on water acidulated vrith muriatie acid.- The interest thus turns 
on the way in which the pepsine acts in conferring this power on the aci- 
dulated water ; and on this point chemists are at^issue. There are different 
shades of opinion, but, speaking generally, the theorists may be divided 
into two classes : 1st, Those who, along with Berzelius, represent the pep- 
sine as acting cataiyHcailpf i, e. as determining the solution of the food by 
its mere contact with it, without taking from it or adding to it, or itself 
undergoing any change ; and, 2dy Those who agree with Liebig in repre- 
senting the pepsine as an efficient cause of alteration in the food, solely 
because its own paiticles are in a state of decomposition or transformation. 

Liebig does not use the term ** pepsine," but I employ it, in explaining 
his views, for the sake of convenience. His own words are, " The clear 
gastric juice contains a substance in a state of transformation, by the con- 
tact of which with those constituents of the food which by themselves are 
insoluble in water, the latter acquire, in virtue of a new grouping of their 
atoms^ the property of dissolving in that fluid." Pepsine is thus repre- 
sented as bearing the same relation to the food whose digestion it effects, 
that yeast does to the sugar which it ferments ; the difference being, that 
in digesticm the elements of the food assume a new arrangement, without 
separating into two or more groups, whereas in the vinous fermentation 
{ex,gr,) those of the sugar are broken up into alcohol and carbonic acid. 

Without entering into any discussion of these opposite views of diges- 
tion, I adopt that of Liebig as the more probable and tuigible of the two, and 
apply it to the eases before us in the following way : 

The transforming action which pepsine exerts on the food is limited in 
the normal state to rendering its insoluble portions soluble in the gastric 
juice. But all the azotised bodies, such as diastase, yeast, albumen, 
casdne, which play the part o( ferments, and among which pepsine 
b ranked, pass through several stipes of decomposition whilst performing 
this function, and modify the non-azotised bodies (such as sugar) on which 
they act, in a different way, according to the state of decomposition in 
which they are. Thus, when fresh milk is exposed in open vessels, 
its caseine becomes altered l^ the action of the air, and ferments the sugar 
of milk which accompanies it ; the latter being transformed into alcohol 
and carbonic acid, into lactic acid, or into a mixture of these, according to 
the stc^ of decomposition which the caseine has reached. In the same 
way a piece of fresh bladder, which at first has no action on a solution of 
sugar, after exposure to the air, acquires the power, according to its state of 
decomposition, of resolving it into lactic acid, into mannite and mucilage, 
or into alcohol and carbonic acid.* 

From these considerations it appears, that, within certain limits, if the 
mode of decomposition of the foment alteis, the mode of decomposition of 
the fermented body must alter also. The constant resolution of sugar into 
alcohol and carbonic acid, which constitutes the vinous fermentation, is the 
result or reflection of an equally c<mstant though'quite different decompo- 
sition in the ferment which occasions it. When the latter decomposes in 
another way, the former reflects the change by decomposing in a new way 
also, and the lactic fermentation {ex, gr,) replaces the vinous. 

In the same way, if normal digestion, t. e. the resolution of the food into 

• See a paper by Boutron and Freniy, in the Annalea de Ch. et de Ph., tome xii. 



190 WATBR-BRASH. 

certain soluble compounds^ be the vesult of a eonstant decompofiition of the 
pepsine in one way, it must be liable to be rendered abnormaly and the food 
to be resolved into quite different products, by the pepsine decomposing in 
a different way. I look upon the cases before us as presenting derange- 
ments of digestion of this kind. All the chemical phenomena they ex- 
hibited led me to look upon the stomach as the seat of a fermentation ; but 
whilst seeking for a ferment to account for this, I have been saved tbe 
necessity of assuming any absolutely new one by Lkbig's view, which repre- 
sents normal digestion itself as a fermentatum, and pepsine as a ferment. 
I suppose, accordingly, that the carbonic, acetic, and lactic acids found in 
such abundance in the ejected liquid, were products of the fermentation (a 
transformation of the food (probably of its non-aasotised or saccharine and 
amylaceous portions) determined by its contact with the modified pepsine. 
As caseine, by a slight alteration in its condition determined by the actimi 
of the air, induces the lactic instead of the vinous fermentation in sugar, so 
we may believe that pepaine, in virtue of a nmilar change, determined in 
the same way, decomposes the food into these acids, instead of siinply 
effecting its solution. 

It is possible, perhaps, to carry our speculations £Eurther. In the second 
case no free muriatic acid was found ; in the first, throughout the whole 
course of the disease, it was detected only in very small quantity. A 
diminution in the quantity of muriatic add secreted by the stomach, may 
be the cause of the abnormal decomposition of the pepaine^ and the corres- 
ponding abnormal decomposition of the food. I mention this here, not for 
the sake of pursuing the speculation, but to direct the attention of those 
who may meet with new cases of the aarcina and acid watei^brash, to the 
question whether muriatic acid be present in the liquid or not, as an im- 
portant datum for future conclusions.* 



NOTICE. 

A paper utas prepared by Professor Auson and intended for thU number. It 
has been unfortunately mislaid^ but we hope to be able to insert it in our 
next, — Editors. 



Part II.— REVIEWS. 



Lectures on the Theory and Practice of Midwifery. By Robert Lbb, M.D., 
F.R.S. 8yo, pp. 553. Longman, Brown, Green, and Longmans, 1844. 

CoNsiDERixo the unwearied industry with which the sayings and doings of 
Dr Robert Lee have been reported by the periodical press for years past, 
and the extravagant plaudits which have been so unsparingly bestowed on 
bis exertions, it may be deemed a bold step of infant journalists, such as we 
•re, to undertake the analysis of his prelections. As these discourses, how- 
ever, have now been twice revised,— ^r«l, for circulation in the London 
Medical Gaaette, and seeandfyy for republication in the volume before us, 
and, as this great master of the o bstetric art informs us, at the « desiie 

* It woald be a favour to Mr Goodsdr mod myself if any inactitioiier nceting 
with a case of acid water-brash would send a specimen of the ejected matter lor 
examinaUon to mj Laboratory, 24 Brown Square, Edinbargb G. W. 



THEORY AND PRACTICE OF MIDWIFERY. 191 

sirongly espraned by many students and practitioners," it might be con«> 
sidered a dereliction of duty were we not to state our opinions respecting 

them. 

Dr Lee is a man of ability ; but it is quite possible for a man of ability to 
write an indifferent book on midwifery. 

The introductory lecture is in the discursive rein. The lecturer has 
followed the Horatian precept, **in mediaa reSy* with a witness. He tonches on 
many points which the student cannot possibly understand, his object being 
in the first instance to exhibit the manifold dangers to which women are 
SQbjected in child-bearing and labour. The eyidence on this head is summed 
up with a statistical view of the mortality among pregnant women, and 
women during and after parturition in different countries and institutions. 
He then turns to a history of midwifery in ancient times among the Israel- 
iies and Greeks, and dwells on the attainments of Hippocrates in this 
line. We are amused with his zeal in behalf of the obstetric knowledge 
of Hippocrates, which it must be confessed was somewhat deficient, at 
least in precision ; for though Hippocrates, it appears, anticipated Am- 
brose Pare in the proposal to turn, yet his project of turning was in the 
wrong direction. We do not indeed observe at first sight from Dr Lee's 
aoGonnt any thing of which Hipprocates was ignorant that accoucheurs 
know at present, except that he had no insight into the nerves of the uterus^ 
and that he failed to discover that an olive, lying across the inside of the 
mouth of a jar, like a cross birth, had not the head, legs, or arms of a ma- 
ture foetus. 

After this follow a few well-assorted and instructive paragraphs, quoted 
from Pare, regarding his proposal of turning, and bringing down the foetus 
by the feet ; there are then a few brief remarks on the advancements and addi- 
tions to obstetric science and art made by Guillemeau and Chamberlayne, after 
them the names of Smellie and Mauriceau are but barely mentioned ; but 
what has become of Rcederer, of the Steins, the Siebolds, the Osianders, 
the Naegeles, and the long time-honoured list of our own countrymen ! 

The only other discovery which appears to Dr Lee at all to approximate 
in importcmce to that of the version of the foetifs, is his own so-called dis- 
covery of the uterine nerves. Even granting that Dr Lee's dissections display 
nerves, which is very much doubted by many who have inspected them, 
we think that matter of much greater utility and interest might have been 
given in an introductory lecture than an anatomical detail of parts which 
may turn out to be in a great measure fanciful. An excellent sentence 
concludes the lecture, but it too is a quotation from Sir Joshua Reynolds. 
We have now done with this discursive prologue, and proceed to examine 
the character and value of the instruction afforded to the pupils of St 
George's Hospital School. The description of the bones of the pelvis is 
excessively meagre and incomplete ; it is in some places so loosely worded 
as to lead to an erroneous idea of the parts, and in fact is but a bare anatomy 
of knobs and holes. We would lay part of this before our readers to bear 
out our statement, but other errors or omissions of greater importance claim 
our notice. 

The inclination, muscles^ and blood-vessels of the pelvis are thus briefly 
discussed : — *^ The plane of the brim is inclined downward and forward so 
as to form a great angle wiih the vertebral column" (p. 17) ; any thing be- 
tween 90 and 180 degrees being quite inmiaterial to Dr Lee. " In the 
living body the psqc muscles, with the iliac blood-vessels, extend along the 
sides of the brim of the pelvis, and modify its form; " the modification of 



192 THEORY AND PRACTICE OF MIDWIFERY. 

the form of the brim does not appear to be worth mentiomog. We had 
thought that all circumstances tending to modify the form of the pelvis, 
however slightly, in part or in whole, were of the utmost importance in 
practice. The characteristics of the male and female pelvis are despatched 
in a line or two, as follows : — ^' The bones of the male pelvis are stronger and 
thicker tlian in the female, the cavity is less capacious, and the pubic sich. 
is smaller," p. 18. In fad, we believe the description of the pelvis as given 
by Dr Lee to be the poorest and most meagre in print. 

The next subject which Dr Lee considers is Disease of the Articulations 
and Bones of the Pelvis. Of the deformities caused by these he gives three 
varieties only — lst,That arising from arrestof development ; 2dly, Frommala- 
costeon ; and, ddly. From rachitis ; the varieties arising from exostosis are 
only named, and that described by Naegele das sdirdg eerengte Becken, or, 
as translated, ** the obliquely contracted pelvis," is not once alluded to. 
In speaking of the first variety, Dr Lee says, ** In some women the pelvis is 
not developed in the usual manner, cmd it remains small through life, al- 
though not distorted. Its condition is very different from what it is in 
childhood." The doctor appears to be unaware that there are two species 
of this variety .: one of these he has described in a style which is confused, 
and we are confident unintelligible^ to the mere student ; but the second, 
where the pelvis remains precisely as it was in childhood, even to the carti- 
laginous junctions of the bones composing the os innominatum, he has 
entirely omitted.* The distinctive characters of the rachitic pelvis, and 
that deformed from malacosteon, are so jumbled together, that we are unable 
to extricate them from the maze of confusion. This, however, is sufficientiy 
accounted for by the doctor stating afterwards, " that the chajiges produced 
by rickets do not difiPer essentially from those observed in malacosteon.'* 
Although this is a doctrine which is held by many, and although we see 
pel vises, in the museums of those who should know better, indiscriminately 
labelled " rachitis," or " malacosteon," as if a shower of labels had Mien on 
them accidentally, we can by no means assent to the opinion ; and we cer- 
tainly agree with the statement that " it is not the difierence in the disease 
that gives rise to the deformities characteristic of the two afifections, but 
that it is the difierence in the condition of the pelvis, at the periods at which 
it suffers from them ;"t for it is in infancy that the pelvis is attacked by 
rachitis, but it is after puberty that it suffers from m^costeon. 

The third lecture treats of the " Anatomy of the XJnimpregnated Uterus 
and its Appendages." It is not so full as we could wish, nor are the details 
given with that pointedness and preciseness which are so necessary in de- 
scriptive anatomy ; for example, the situation of the uterus is thus de- 
scribed : — ** The uterus is situated within the pelvis, behind the bladder, 
before the rectum, below the small intestines, and above the vagina ;" we 
might almost as well have been told that the uterus is within the skin, above 
the heels, and below the eyes. In this lecture, also, on the unimpregnated 
uteruSy the doctor is rather excursive, for he branches away to the question 
of the presence of a decidua in extra-uterine gestation, and as to whether 
phlegmasia dolens depends on inflammation of the pelvic veins or not. 

The fourth lecture, comprising the " Physiology of the Unimpregnated 
Uterus and its Appendages," is good and interesting ; it contains much that 
is valuable in the shape of statistics of menstruation, and several important 

* Naegele das schrftg verengte Becken, s. 101. 
f Campbeirs System of Midwifery, p. 674. 



THEORY AND PRACTICE OP MIDWIFERY- 193 

dissections in support of the theory that this secretion is canscd hy 
hypersmia of the uterus, consequent upon the escape of Graafian vesicles 
from, the OTary. We shall not fiitigue our readers with any discussion as 
to the priority of claim to this theory ; for during the last month the pages 
of our journals have teemed with letters on this suhject, from Dr Lee, his 
partisans, and their opponents. This much we know, that certain anatomical 
specimens, relating to this suhject, were shown hy Dr Girdwood to Dr Lee 
previous to Dr L.'s puhlication of his views on the matter. 

The next lecture contains a good description of the corpus luteum, 
though rather too much of it is taken up with the question, as to whether 
the yellow matter is developed hetween the tunics of the Graafian vesicle 
or without the outer coat. Dr Lee here states, " that not unfrequently 
two corpora lutea are present in the ovaria, where there is only one ovum 
within the uterus." This taken to the letter is correct, hut is extremely 
apt to lead to a false inference. If the doctor means that two corpora 
lutea may he found where one ovulum only has been impregnated, we 
must refose our assent to his belief ; for we have never seen or heard of 
any unequivocal instance of such an occurrence, Dr Montgomery, though 
he mentions one or two observations of this nature, details them in a 
manner so hesitating, that we are inclined to believe he attaches no credit 
to them ; and we think Bailer's statement " numerus corporum luteorum est 
in ratione foBtuum*' is still uncontradicted. The lecturer continues : ** I 
found a perfect corpus luteum in the ovary of a woman who died from in- 
flammation of the uterus, soon after the expulsion of a mass of serous cysts, or 
hydatids, as they are termed." We are happy to have this statement from 
the doctor, in corroboration of the opinion that the so-called hydatids are 
merely a dropsical degeneration of the tunics of the ovum, and that their 
presence is an evidence of impregnation having been effected, — a feet which, 
had it been ascertained at that time, would have been of much value on 
the well-known trial of Mr Angus of Liverpool. 

As in a work on midwifery, those portions which treat of practice are, or 
ought to be, the most valuable and highly finished, we must be held ex- 
cused if we treat with some brevity of the remaining lectures on the 
anatomy and physiology of the uterus and ovum. Lectures 6th, 7th, and 
8th, contain nothing sufficiently important to demand observation. The 
9th lecture, though we cannot concur with all therein affirmed, is excellent, 
and, with other valuable matter, contains an unanswerable contradiction to 
the advocates of the ** double night-cap decidua." As the preparation 
from which Dr Lee was enabled to demonstrate the incorrectness of their 
position is probably unique, we shall extract the description. It was a 
litems in the second month of pregnancy, having the placenta attached 
chiefly over the cervix, taken from the body of a woman who had 
poisoned herself. 

"If," says Dr L., "you examine this gravid uterus of two months, 
you will see the chorion and amnion enclosing the embryo and 
umbilical cord, and the placenta covered with its decidua adhering 
all round to the upper part of the neck of the uterus. You w^ill also 
see clearly, that the decidua reflexa lies entirely above the villi of the 
chorion, on that side of the ovum where the placenta does not exist, and 
where the ovum is not attached to the uterus. In all the diagrams from 
Dr Hunter, Wagner, and other anatomists which you have seen, the 
placenta has invariably been represented as adhering to the fundus uteri, 
and the decidua reflexa has been situated near the cervix, and appearing as 

2b 



li^4 THEORY AXU PRACTICE OF MIDWIFERY, 

if mechanically depressed or pushed down befoie the ehorion or oyuio. 
But in this preparation it is obvious that the decidua reflexa eould not 
have been puslied down before the ovum, because it lies above or covers 
the ovum,— the ovum lies between the decidua reflexa and the cervix 
uteri, and as the oviun enlarged, the decidua reflexa must have been forced 
upward to the fundus uteri, which was lined with the decidua rera, instead 
of downward to the cervix. The decidual cavity is, you observe, at the 
fundus uteri, above the ovum, and both Fallopian tubes open into this cavity 
by palpable orifices. Instead of being covered with the uterine decidua, 
this membrane passes into them, and they are left completely pervious, so 
that no membrane existed which the ovum could mechanically push before 
it." P. 80. 

These facts show that the decidua does not form a shut sac in the early 
months of pregnancy, but that the openings of the Fallopian tubes are 
permanent, and that therefore there exists no membrane which the ovum 
can push before it to form the decidua reflexa. The lecture concludes 
with the doctor's views of the uses of the decidual cavity ; they appear to 
us to rest on but very feeble grounds, and to be in much need of confirma- 
tion from other observers. 

The 10th lecture contains a tolerably good account of the growth of the 
uterus, its nerves and vessels, during gestation ; the 11th is entirely the 
doctor's own, embracing solely his nerves and ganglia. The 12th, 13th, 
and 14th lectures, on the membranes of the ovum, cord, placenta, and foetal 
peculiarities, are good ; the last, however, is rather meagre, as it attempts 
to include too much. We are surprised to find in the 15th lecture the 
signs of pregnancy handled with such brevity ; many that ought to have 
been mentioned in a lecture are omitted, and the sign which in our estima>- 
tion is second only to the sound of the foetal heart, viz., internal ballotte- 
ment, is treated most superciliously. The doctw ofi&rms also, that ballottement 
per vagiruim is better ascertained with the female lying in the usual labour 
position than in the erect posture. Such a dictum we should expect from 
one who had never attempted a vaginal examination in the erect position ; 
for the idea is totally opposed to reason, to conmion sense, and to fiict. 
The 16th lecture contains a series of cases of concealed, feigned, and com* 
plicated pregnancy, possessing but little interest. 

The 17ih and 18th lectures are devoted to the oonaderation of extra- 
uterine gestation and abortion. The former of these subjects is miserably 
defective, ibr all that the lecturer communicates regarding it is contained 
in two pagea and a half. Dr Lee, whether from ignorance of its literature, 
or that it would be derogating from his importance to consult contemporary 
authorities, traces its history, not from the time of Albucaais of the 11^ 
oentmy, but from that of Riolanus of 1650. He takes no notice of the 
excellent communication and ingenious views of Dezeimeria^ nor of the 
elaborate memoir of Dr Campbell. Four lines contain all that is said of 
the symptoms ; he is altogeUier silent r^;arding the diagnosis^ and tiiere 
is not a word on the subject of causes. Our author is hostile to the attempt 
of emancipating the foetus alive, without stating any reasons ; and as we 
are equally opposed to this measure, we shsJl mention the has^ on which 
our objections are founded. Gestation is a period, owing to the h^hly ex- 
cited ^te of the noTous system, and the consequent &citity with which 
genual disturbance is produced, that is most un&vouiable to soigicfll 
operations. Hence, of nine women who were operated on while the fetus 
WIS alive, or shortly after its life became extinct, not one survived ; while 



THEORY AND PRACTICE OF MIDWIFERY* 195 

of foHy on whom gasirotomy was performed, or the dilatation of an 
ulcerated opening in the parietes of the abdomen was practised some time 
sabsequent to the death of the foetus, thirty-six had so complete a recovery 
that many of tk^n produced living children afterwards. The remainder of 
this lecture and the whole of the next are devoted to the consideration of 
the causes^ symptoms, and treatment of abortion ; and although there is 
nothing novel in the discourse, the lecturer nevertheless appears to con- 
siderable advantage, from the attention which he seems to have bestowed on 
the pathology of the ovum. 

Among the averments in this lecture, we cannot overlook the following 
(p. 175), viz., " that abortion is ofUn one of the first symptoms of ma- 
lignant disease of the uterus, and women who have in the walls of the 
uterus a number of fibrous tumours embedded, never carry their children 
till the full time." The word " often " would appear to hold an elevated rank 
in the vocabulary of Dr Lee ; but it seems to us to be too frequently em- 
ployed by him incorrectly, as in the foregoing passages, though we hope, 
for charity's sake, without the usual signification. We positively deny 
that abortion is often one of the first symptoms of malignant disease of the 
uterus ; and in support of our assertion we need merely refer to Dr Lever's 
veiy interesting statistics (Med. Chir. Trans., London, vol. xxii. p. 267), 
wherein we are informed, that of 113 women who had carcinoma uteri, 
forty per cent, only had miscarried ; and as for ourselves, in no instance 
that fell under our observation, where there was malignant disease of the 
uterus during gestation, did either abortion or premature labour happen. 
And in regard to the second opinion advanced by Dr Lee, we regret to find 
that he has profited so little by his pathological industry as to be unaware 
that individuals with fibrous tumours embedded in the walls of the uterus 
may advance in their gestation to the natural term. Several instances are 
known to us where pregnancy was completed under these latter circum- 
stances, but where the event was disastrous in consequence of uncontrollable 
hemorrhage. 

We concur with the lecturer in thinking that the expression ^ habit of 
aborting," as fi^plied to females who have repeatedly experienced this acci- 
dent) is insufficient to account for the cause, which, independently of some 
morbid condition of the membranes, placenta, or fcetus, may often admit 
of a very different explanation. As local or uterine debility and consequent 
plethora are almost invariable results, even where miscarriage has only 
once happened, it seems reasonable in many cases to ascribe the accident to 
these conditions ; and the rather, since it is well known that frequently, by 
temporarily suspending the procreative function, and thus affording an 
opportunity for the tone of the reproductive system to be improved, the 
disposition to abortion is removed. 

Among the causes of abortion, syphilis and mercury are specified by our 
author ; and he believes them boUi to act as specific poisons which destroy 
the vitality of the foetus. The influence of the first of these must be 
&miliar to men even of moderate practical information in midwifery, 
though its modus operandi must be pure conjecture ; and in regard to the 
latter, though, in cases where there is a predisposition to abortion, mercury 
will occasion this accident with as much certainty as the former, yet the 
hare idea of its acting as a specific poison is such a perversion of known 
ftcts, that it is difficult to conceive how Dr Lee could have brought him- 
self to advance so rash an opinion. We cannot for a moment suppose him 
to be ignorant that mercury is frequently exhibited, during pregnancy, to 



196 THEORY AND PRACTICE OF MIDWIFERY. 

females who have often previously aborted owing to the foetus being con- 
taminated by 83rphilis, and that instead of poisoning, it preserves the fcetua, 
which is bom alive. We have known females illegitimately pregnant 
unmercifully salivated with the criminal intention of procuring abortion, 
but unsuccessfully, as the foetus was bom alive, and even appeared plump 
and vigorous. And we have known pregnant women severely salivated by 
mistake, upon the supposition of their having ovarian disease, but without 
any detriment whatever to the foetus. 

When the use of mercury is followed by abortion or premature labour, 
the accident will admit of a very diilferent and quite as satisfactory an ex- 
planation, — ^it must be ascribed to local excitement and consequent injury 
to the utero-placental vessels. And, accordingly, Dr Lee himself informs 
us, and we happen to be familiar with the fact, that when mercury is 
exhibited to an undue extent during gestation, fatal hemorrhage may be 
the result. Calomel we have known, where it was taken in an over-dose, 
induce premature labour and fatal hemorrhage, by occaaoning severe irrita- 
tion of the bowels, propagated to the uterus, and followed by excitation of 
its fibres and premature detachment of the placenta. 

Dr Lee terminates his enumeration of the causes of abortion by particu- 
larizing knots on the funis, and the latter being firmly entwined round the 
neck of the foetus. Of several foetuses, with knots on the umbilical cord, 
which we have seen, all were bom alive except one, which had been 
destroyed by syphilis. And we have yet to learn how the foetus before 
birth can be destroyed by the cord being firmly drawn round its neck, 
except by preventing the return of the blood from the brain, which is just 
barely possible ; and, accordingly, we have never yet seen a dead foetus 
produced under such circumstances. 

The 19th lecture is occupied with observations on the transmission to the 
foetus in utero of scarlatina, rubeola, variola, and syphilis ; and on dropsy 
of the amnion. Of this last some very instructive cases are added in iUu»- 
tration ; but in his diagnostic marks Dr Lee is very meagre. We are not 
told that the foetus is reached per vaginam with difiiculty, and felt very 
indistinctly ; that its movements are communicated but obscurely to the 
parent ; that her abdomen enlarges with rapidity ; that her general health 
may be unaffected until an advanced stage of pregnancy ; and that there 
is then the most distressing dyspnoea. 

The 20th lecture is an exceedingly rambling discourse. The teacher 
begins with varices of the pelvic limbs, advances to the uteras, whence, 
quite unexpectedly, he jumps to the head, and thereafter he wheels about 
to the thorax. Though, to speak phrenologically, Dr Lee's work aflPords 
evidence that some of his organs — ^for example that of Self.esteem — are 
highly developed, yet hb region of Order must be a perfect blank. The 
subjects comprehended in this lecture are sadly jumbled together, and do 
not contain a single new idea. We pass on to the 2l8t lecture, which intro- 
duces us to the important subject of parturition. The first thing by which 
we are remarkably stmck here is Dr Lee's great talent for condensation. 
Though we readily admit that comparisons are odious, yet we cannot help 
contrasting the amount of matter furnished by Dr Lee on natural labour 
with that which is contained in recent systematic works in our own lan- 
guage on the same subject. In the work of Dr Eamsbotham, jun., and 
some other systems published of late, we find at least three times as much 
information on natural labour as in Dr Lee's lecture. We admit that it is 
quite possible for one man to convey as much instruction in two lines as 



THEORY AND PRACTICE OF MIDWIFERY. 197 

another in six ; but, be this as it may, we have no hesitation in stating that 
Dr Lee's lecture on natural labour is exceedingly meagre ; for if there be 
any one divi^on of parturition on which a teacher ought to dilate more 
than another, natural labour is that diyision, since the conduct of the prac- 
titioner in every other variety of parturition must be guided by the rules 
which ought to regulate his proceedings in the management of natural 
labour. 

Although we have some idea where Dr Lee acquired a part of his ele- 
mentaiy obstetric education, we presume that he is entirely indebted to the 
nice turn of his own mind for the following delicate precept — ^that the 
practitioner, in proceeding to make an examination, is to advance ** the fore- 
fing^ of the right hand to the anus, and along the perinceum to the vagirta** 
If the lecturer's aim be originality, as £Eur as our knowledge goes he has 
completely attained his object ; and we are very sure that no man posses- 
sing delicacy of feeling will attempt to deprive him of, nor indeed envy him, 
the merit of priority ; for of all the methods we have heard of, this is un- 
questionably the most offensive. To those of our brethren who are 
unacquainted with midwifery practice, it may seem of little moment, pro- 
vided the parts be not exposed, in what manner the examination is con- 
ducted ; but to those who devote their attention to this department of the 
profession, it must be well known that indelicacy or maladroitness in the 
performance of this duty is not unfrequently the cause of the practitioner's 
dismissal. We shall not insult our readers by pointing out the method 
which should be pursued, as this will readily suggest itself to every man of 



The next passage in the same lecture, deserving the particular attention 
of our readens, is one containing sentiments which we certainly never ex- 
pected to find inculcated by any one pretending to a scientific and practical 
knowledge of midwifery : — 

" In no case is,it necessary or proper at the commencement of the labour, 
before the membranes are ruptui-ed, and the first stage completed, to 
endeavour to discover in what position the head of the child is placed 
relatively to the pelvis of the mother ; it is enough to know with absolute 
certainty that the head presents." — " Any attempt to determine in wliicli 
of the numerous positions described by some authors the head is placed at 
the brim of the pelvis, would only endanger the rupture of the membranes, 
and disturb the regular order observed by nature in the process. I am 
greatly at a loss to discover what benefit could result from knowing, during 
Uie fi^t stage of labour, provided you can touch the vertex with the point 
of the finger, in which of the six or eight positions of Bandelocque, and 
other foreign authors, the head is placed." P. 223. 

Although we are unwilling to believe that Dr Lee, notwithstanding 
his love for originality, could have had any intention to mislead his pupils, 
we do not, however, hesitate to maintain, that the foregoing precepts are 
not only at variance with the experience of every practitioner of midwifery 
gifted with the power of observation, but certain, if acted on, to be produc- 
tive, in many instances, of a great amount of suffering to the patient. It 
is so far necessary during the first stage, and if possible before the mem- 
branes have been ruptured, to decide the position of the head, that unless 
we have a correct knowledge of it, we iSiould give an erroneous opinion 
regarding the manner in which the labour might terminate, its duration, 
and the degree of suffering which the patient might be compelled to endure ; 
on all of which points the parties concerned are not only most anxious to 



108 THEORY AND PRACTICE OF MIDWIFERY. 

know our opinion, but insist on being informed. Secondly, by discovering 
in the early part of the first stage an unfavourable position of the head, the 
practitioner, unless he confide in the mischievous principles inculcated by 
Dr Lee, will watch the case, that, when uterine dilatation is sufficiently far 
advanced, he may embrace an opportunity, before the menrbranes have 
burst, of endeavouring to rectify the position of the head, should this be 
necessary ; for, after it has considerably advanced through the brim in a 
wrong position, and the liquor amnii has escaped, it will almost always be 
difficult, and often impossible, to effect the required change. 

We admit that there are certain positions of the head which -do not call 
for interference ; but there are others in which frequently, if assistance 
be not affi)rded, the patient is obliged to submit to severe and protnfbted 
agony. Every practitioner of candour who has met with such cases will 
acknowledge that when the vertex is placed behind the pubes, or in con- 
tact with the sacrum, the progress, where the powers of the parent are 
relied on, owing to the unsuitable position of the head, is yery slow, and 
the sufferings of the patient much aggravated ; and every man of experi- 
ence will also admit, that when the brow is towards either acetabulum, if 
the face should descend into the pelvic arch, as occasionally happens, that 
the transit of the head in far the greater number of instances is much 
retarded, and the patient's uneasy feelings greatly increased. 

From the 22d to the 26th lecture inclusive, we have the management of 
cases of protraction and difficulty arising under the usual causes, such as 
rigidity of the os uteri, of the membranes of the ovum, and of the external 
parts ; tumours, hard or soft, within the pelvis ; premature ossification and 
preternatural growth of the cranium, hydrocephalus, malposition of the 
head, and shortness of the funis ; and, blended with his observations re- 
garding these varieties of labour, we have also the lecturer's sentiments 
respecting venesection and the exhibition of opium and ergot. 

Although in the 2l8t lecture Dr Lee was at a loss to diseover what bene- 
fit could result from our having in the first stage of labour ab accurate 
knowledge of the position of the head, yet in his 24th discourse we have 
an indirect acknowledgment that such information is extremely valuable. 
By the position not having been recognised, either in consequence of the 
sentiments of Dr Lee being acted on, or from inexperience, and the mal- 
position not being rectified when this could be easily accomplished, an 
un&vourable case is produced. Dr Lee, in speaking of such positions, is 
obliged to confess that, ^ besides the great length of time which may be 
required in moulding and expelling the head, there will also be a great 
distention of the external parts," &c. ; in the second place, he remarks, 
that **• if the labour is much protracted, and the natural powers be insuffi- 
cientfor Us ex/wfoion," &c. ; and in the third place, he observes, that ** no 
unpleasant consequence is produced except a swollen state of the child's 
face firom Umg-ixmtinued pre^eureJ* But we shall immediately see that pro- 
traction of the patient's sufierings, exhaustion of her pow^:s, and tume&c- 
tion of the foetal structures, are not the only evils which will result from 
non-interference, but frequently also the deadi of the foetus. 

We are quite prepared to admit that in many cases of malposition, the 
fiM^ during the advance of the head, turns in the direction of t^e sacrum 
without artificial interference, but whether so frequently as Rigby and the 
other disciples of the Heidelberg school have stated, is what we cannot 
positively affirm. But, admitting this to be the case, would a practitioner 
who had disscovered malposition at such a stage of labour as would easily 



THEORY AND PRACTICE OF MIDWIFERY. 199 

permit the required change, be justified in leaving matters to nature, and 
the woman to be in agony from twelve to sixteen hours, when by very 
simple interference this could be prevented ! We should like to ask Dr 
Collins^ a gentleman in whose candour and experience we have implicit 
confidence, whether, if he had been present at the commencement of each 
of the twelve cases of labour with the face to the pubes referred to by Dr 
Lee, he would have left matters to nature ! and if he would not, whether 
he conscientiously believes that the half of the children would have been 
still-bom ! Notwithstanding the opinions of Dr Lee and others of our 
brethren, we hold that to advocate non-interference, under the foregoing 
circumstances, would betray a degree of callous indifference to the suffer- 
ings of the sex, of which, after mature reflection, it would be difiicult to find 
an example. When such pernicious principles are attempted to be incul- 
cated, Dr Lee and his proselytes could scarcely feel any surprise should the 
London College of Physicians again declare to the Secretary of State for the 
Home Department, "that the most successful practice of midwifery re- 
quires no such laborious preliminary study " (as is necessary for the practice . 
of medicine), " else discreet matrons and plain uneducated men in the 
country, who frequently arrive at great notoriety in this calling, would not 
acquire that credit which they often attain." 

Dr Lee denies the influence of an oblique position of the os uteri in re- 
tarding the first stage of labour ; while he as firmly believes that shortness 
of the umbilical cord has this effect. Candour and practical experience, 
not mere assertion, will decide these points. Let such of our brethren as 
are sceptical regarding the influence of the first, merely introduce a finger 
within the os uteri when it is directed against the sacrum, as sometimes 
happens in first labours, and cautiously draw it into, and for a short time 
retain it in the centre of the brim, when the rapidity with which it will 
dilate must soon convince them of their error. Dr Lee's belief, that short- 
ness of the umbilical cord will retard the expulsion of the foetus, is scarcely 
worthy of comment, because not only the idea but the very words used by 
the lecturer are borrowed without acknowledgment from Dr Denman, one 
of the idols of the doctor's worship ; and because he unintentionally agrees 
with us in thinking that it cannot have this effect, by admitting that, when 
the funis is too short to permit the uninterrupted transit of the foetus, the 
placenta will be detached or the funis itself ruptured, of which last Dr 
Rigby relates a case exactly in point. 

Although we have thus far, as it was our duty to do, exposed the &lla- 
cies of some of Dr Lee's opinions, we do not hesitate, however, to admit 
that his sentiments and practice relative to many important points contained 
in the last five lectures are, to say the least, judicious, decisive, and such as 
were to be expected from a practitioner of industry and experience. We 
have noticed with satisfiiction his strictures on the employment of vene- 
section, opium, and ergot ; and we are glad that the reckless practice of 
incising the os uteri during labour, in cases of rigidity of that aperture, is 
not even mentioned by him, whence we infer that he disapproves of it. 

The 27th, 28th, and 29th discourses may truly be denominated multum 
in parvo, and afford an additional instance of Dr Lee's aptitude for condensa- 
tion ; for in these three lectures we have all his observations on the im- 
portant subjects of the history, objects, and application of the forceps, 
embryotomy, Cflesarian section, and the induction of premature labour. In 
his introductory remarks on the application of forceps (lect. 28, p. 300), 
the lecturer informs us that he " gives the preference, above all others, to 
Dr Denman's short forceps covered with leather:'-^** But in truth I attach 



200 THEORY AND PRACTICE OF MIDWIFERY. 

coinpaiatively little importance to the shape and dimensions of the forceps 
for use." Dr Lee could not hare promulgated a more dangerous senti- 
ment regarding this instrument than that its size is a matter of little 
consequence ; but fortunately we are saved the trouble of any lengthened 
comment on this head by additional light having dawned on the benighted 
intelligence of the lecturer in advancing with this subject ; for in the same 
discourse, at p. 303, we have not only a complete contradiction of the fore- 
going opinion, but what we are sure must be in accordance with the senti- 
nienti of every practitioner pretending to a knowledge of the use of forceps. 
" In order to disable young practitioners from running such risks 
(causing inflammation and laceration of the parts), and to free myself from 
the temptation of using too much force, / have always used and reeom- 
mended the forceps so short in the handles that they cannot be used with 
such violence as will endanger the woman's life," &c. 

The objection, and an insuperable one, to the employment of forceps 
of lengthened dimensions is the amount of power they confer on the 
operator, than which, in the hands of gentlemen entering on practice, there 
cannot be any thing more dangerous. This objection applies to all the 
continental forceps we have seen, even to that used by the distinguished 
professor at Heidelberg, though, from the eagerness with which he has so 
long applied himself to the improvement of a branch of the profession of 
which he is so distinguished an ornament, we had a right to expect that 
the defect in question would not have escaped his penetrating mind. For 
ourselves, we give the preference to the double-curved pair, which also is the 
variety most generally used on the Continent, being originally the sugges- 
tion of Levret ; and if the handles were lengthened by an inch, we do not 
know, of all the piracies which the dabbUng manufacturers of forceps 
have produced, a better instrument than that delineated in the work of 
Dr Wallace Johnson, which on an impartial trial will be found, when pro- 
perly applied, both more safe and efficient than the single-curved pair. 
By a practitioner so ignorant of the subject that he is unable to decide the 
precise position of the head, the single-curved is more easy of management, 
since in such hands we know for certain that forceps are occasionally in- 
troduced at random. 

We concur entirely in the opinions of Dr Lee respecting the objects of 
forceps, and his salutary precautions regarding their use ; but, in Mb 
idolatry of Dr Denman, his sentiments in reference to these instruments 
are blended with notions so antiquated, and with directions for their ap- 
plication so utterly at variance with the experience of all competent practi- 
tioners, Dr Lee himself excepted, that, were we not satisfied of the contrary, 
we should certainly W inclined to infer that the author had much more 
experience in craniotomy than in the application of forceps. To forceps 
covered with leather, as recommended by Denman and preferred by Dr Lee, 
we decidedly object ; firsts becaose this covering, by increasing the 
thickness of the blades of the instrument (and particularly so after 
their immersion in warm water), would render their intioduction more 
difficult, or indeed impossible, in cases of limited free space, but in 
which, without the leather, they might be introduced with comparative 
ease, not only from less room being required, but frtim a polished steel 
instrument sliding more readily over the linings of the pelvis than a 
contrivance covered with a substance which would cause a greater amount 
of friction ; and, «ecoiM%, because we presume it will be admitted that it 
is quite possible, by means of an instrument covered with leather, to convey 
morbid secretions from one subject to another. 



J 



THEORY AND PRACTiCE OF MiDWIFERY. 20t 

If Dr Lee acts la private in accordance with the precepts which he incul- 
cates In his public lectures, we have no hesitation in pronouncing him t(i 
be one of the most indelicate and unfeeling practitioners we have read of 
for some time. This we think tlie following passage from his 28th lectuirey 
p. 307, on the application of forceps^ will fully substantiate : — ** Take a blade 
of the forceps by the handle in your left hand, and pass aU the fingers </ 
ffour right hand, in a conical formy covered with iardy slowly imto the orifice of 
the vagina^ and if it is ajirst chUdy and the parts we contractedy gently dilate 
them and press back the peiinaum. When this has been sufficiently effected, 
pass the four fingers of the right hand forward into the vagina deeplyy as far 
indeed as the root of the thumb, between the head of the child and the front 
of the pel vis," — " I would recommend you to pass all the fingers complete^ 
over the side of the heady so as to feel the ear, and to determine positively to 
which side of the pelvis the occiput is directed." To what reflections the 
foregoing passage may give rise in the breasts of the competent part of our 
brethren, it is not for us to say ; but, for ourselves, we hesitate not to de* 
clare our belief, from abunduit experience in the application of forceps^ 
that not one woman in fifty would submit to the tmnecessary and unfeeling 
practice recommended by Dr Lee ; and that the pelvis is rarely indeed of 
such capacity as to admit the adoption of the steps which he so confidently 
inculcates ; but we shall be charitable enough to suppose, that from his 
primeval origin nature intended Dr Lee for tiie profession of an accouch- 
eur, and that, while she endowed him with the intellect of manhood, she 
purposely furnished him with the hands and fingers of a child. 

As an appropriate introduction to our observations on the conduct of Dr 
Lee in performing embryulcia, we may here notice his directions for ascer- 
taining the presence of deformities of the pelvis. *^ All the morbid con- 
ditions of the pelvis can be ascertaiued with sufficient precision during life 
by introducing the fore-finger of the right hand into the vagina, and 
passing it around the interior of the pelvis. If the point of the finger 
cannot touch the promontory of the sacrum, there is little or no distortion 
of the brim ; and by moving the finger from side to side and backward, it 
will readily be discovered if the tuberosities of the ischia are at the usual 
distance from each other, and if the direction of the sacrum and coccyx is 
altered." Lect. 2, p. 22. These directions for determining the various 
vitiated conditions of the pelvis are miserably defective, and an insult to 
the understanding of intelligent students. No sensible unprofessional 
reader even, not to mention competent practitioners, would for an instant 
suppose that so importcmt a point as that by which the necessity of de- 
stroying a human being is to be determined, would be disposed of so sum- 
marily by a master in the art. 

We were in hopes of being saved the necessity of commenting on the 
subject of embryotomy ; but here again we cannot conceal our dissatis£ebctioa 
at the conduct of Dr Lee. In the course of twenty years he assisted at 127 
cases of eAbryulcia, which amount of practice might be thought sufficient 
not only to qualify him for deciding with little hesitation on the necessity 
of the operation, and performing it with dexterity, but also for acting with 
such caution and tenderness as to secure, as &r as human aid could accom- 
plish, the safety of the parent. Far be it from us to insinuate even that 
the head was, in any (me instance, perforated unnecessarily ; but we uo- 
hesitatingly state that, in some instances at least, it was not done with 
caution, and that consideration for the safety of the parent which ought 
to have been observed, and which may perhaps explain in some degree th« 

2o 



202 THEORY AND PRACTICE OF MIDWIFERY* 

mortality that followed the operation, 23 of the 127 operated on having 
died after it. 

In consulting Dr Lee's Clinical Midwifery, we find abundant evidence of 
the fortiter in modo. Thus, in case 66, ^ Great force required to extract ; 
case 76, great force required to drag the shoulders into the cavity of the 
pelyig ; case 78, great force was required to extract the head after being 
opened ; case 86, we were both thoroughly exhausted before the delivery 
was accomplished ; case 129, after much exertion, continued for nearly two 
hours, the head was at last extracted when completely torn to pieces ; case 
136, great force was required to extract the head ; case 145, the head would 
not follow — I pulled strongly upon the neck — ^the perforator and crotchet 
were employed — the delivery was at last effected, but death took place 
five days after from uterine phlebitis ; case 146, the bones of the upper 
part of the head were all torn to pieces, and the fingers of my left hand 
much injured, before the delivery was effected ; case 160, the point of the 
crotchet was fixed on the base of the skull, and strong traction made for 
aome time ; at last I succeeded in extracting the head with the bones all 
crushed together. After this severe and tedious operation she was left in a 
yery exhausted state, and died the following day with vomiting and other 
symptoms of ruptured uterus. On examining the body after death, we 
found the muscular coat of the anterior part of the neck of the uteros 
lacerated. Case 161, though / exerted my u^wle farce In dragging down the 
head, it would not pass." P. 36—76. 

Had Dr Lee been contemporary with Philomenus, nothing more barbar- 
ous was to be expected than the management of some of the cases specified ; 
for the sole object of this last author, as would appear from the writings of 
^tius, lib. xvi. c. 23, vras to extract the foetus in any way that this could 
be accomplished ; and if we are to judge from Dr Lee's proceedings, per- 
foration and the most forcible traction constitute in his hands the basis of 
operative midwifery. Even Celsus, barbarous as the practice of midwifery 
was in his day, would appear to have acted with more caution than Dr Lee ; 
for he says, lib. vii. c. 29, ** Nam ei eummam prudentiam moderatkmemque 
deeiderat^ et maximum perieuhim ctffert** Every one who has been concerned 
in performing embryotomy must be aware that a considerable degree of 
traction must be exerted fi>r the extraction of the foetus, even where the 
confinement of the pelvis is not remarkable ; and therefore we do not 
blame Dr Lee so much for the efibrts which he made, as for his having dis- 
regarded the most important precaution previously to attempting delivery 
^-of reducing the size of the bones of the cranium, that during their extrac- 
tion the certainty of injurious friction against the structures of the parent 
might be diminished. Neither does it appear, from the details of the cases 
related, that, with a view to the preservation of the maternal structures, 
evisceration of the thorax or abdomen had been practised. No one can 
peruse this section of Dr Lee's course without observing that, like the late 
1^ Fielding Ould and Dr Osborne, his grand aim is to show that the Ccsa- 
rkn section may be dispensed with ; but although we are by no means 
friendly to that operation, and readily admit that by foreigners it was, and 
still is, resorted to where it would never be thought of by Britiah practi- 
tioneis^ yet we are decidedly of opinion that no one can reflect on the vio- 
lence which must have been inflicted on some of Dr Lee's patients, without 
being satisfied that they would have had fully as good a chance of recovery 
after the Ccsarian operation, and the additional advantage, in some of them 
at least, of one life being saved. 



THEORY AND PRACTICE OF MIDWIFERY. 203 

In coaclading our strictures on cases requiring the crotchet, we cannot 
pass unnoticed a statement made by Dr Lee in the 141st and two succeeding 
deliveries* — ^that he introduced his hand and turned in a pelvis of which 
the distance, estimated during life, between the tuberosities of the ischia was 
only one and a half inch ; but although this patient died subsequently 
under his management, the dimensions of her pelvis are not supplied, whidi, 
to say the least, must place the candour of Dr Lee in a peculiar position. 

As was to be expected, the observations of Dr Lee on the Cssarian section 
are not only meagre in the extreme, but almost devoid of useful information. 
Although we are as hostile to this expedient as he is, yet, as we are satisfied 
^t practitioners may occasionally be called upon to perform it, his lectures 
ought to have embraced a proper detail of the steps of the operation, since 
it is quite possible that on some occasions an operator may have no other 
work to consult. 

We entirely agree with the lecturer as to the safety of the induction of 
piemature labour in as fJEir as the parent is concerned, and that it ought to 
be resorted to in all cases at such a stage of pregnancy as may be required, 
according to the estimated amount of deformity in the living state, to pre- 
vent our endangering the maternal structures by embryulcia, or the patient 
belog compelled to submit to the Cesarian operation. But though punc- 
turing the membranes^ when done with caution, may be safe as regards the 
parent, yet we haye always been of opinion, and our belief is confirmed by 
the results of some of Dr Lee's cases, that the early evacuation of the liquor 
amnii is often destructive to the foetus, in consequence of the pressure to 
which it is thereafter more directiy exposed from the contractions of the 
uterus. Wherefore, when our object is to preserve the foetus, we have 
always preferred to the perforation the separation of the membranes from 
the uterus, — a practice which has invariably succeeded under our manage- 
ment to induce premature labour. In perusing the observations of Dr Lee 
en preternatural labours, it nowhere appears that he exhibited opium to 
relax the uterus previously to his undertaking the version of the foetus after 
the escape of the liquor amnii. We can conceive no good reason for his 
dispensing with this invaluable agent under such circumstances, but the 
very reverse indeed ; and we think that if it had been exhibited, Dr Lee's 
cases of ruptured uterus would not have been so numerous. 

The remaining lectures include the important subjects of uterine hemor- 
rhage, convulsions, inversion of the uterus, rupture of this organ, inflamma- 
tion of the organs of reproduction, phlegmasia dolens, mania, engorgement 
and inflammation of the mamme, and ulceration of the nipples. Li the 
perusal of these discourses there is little to find &ult with, for pathological 
investigation appears to be the forte of Dr Lee, — as an obstetric practitioner 
he aj^eazs to littie advantage. Of some recent opinions and practical im- 
provements, however, whether from ignorance, jealousy of his contempo- 
raries—one of his besetting sins — or because it would be derogatory to his 
reputation, he takes no notice. 

In bringing to a conclusion our analysis of Dr Lee's labours, it is not ne- 
cessaiy for us to say that we are exceedingly disappointed, for this will be 
read in almost every page of our observations. As a guide for students we 
cannot recommend these lectures, especiaUy when those finished productions 
of Drs Blundell and Bamsbotham can be consulted, which the prosy pre- 
lections of Dr Lee resemble merely in name. We can aver that the die- 

* Clinical Midwifery, p. 73« 



204 ANATOMY AND PHILOSOPHY OF EXPRESSION. 

eounes of Dr Lee do not contain any information of practical importance bir " 
what must be perfectly familiar to snch of our Vi^ethren as poesesaa moder^ 
ate knowledge of the literature of their profession ; and, therefore, that o* 
all the productions in midwifery which have recently issued from the preset 
these lectures will be found, on perusal by competent judges, to be the leasfl 
deserving of the honour of a place in a select medical library. 



\ 



The Anatomy and Philosophy of Expression as connected with the Fine ArU,m=^r, 
By Sir Charles Bell, K.H. 3d Edition, enlai*ged. 9vo,, pp. 26 4 . 
London. 1844. 

This elegant contribution to philosophy and the fine arts, was the eaillest^^B 
and latest work of a distinguished anatomist, a man of taste and of genius^^"- 
Although first published in 1806, it was originally composed during th w i ^ 
period of his studies, ** before the serious pursuits of life began." With the^^^ 
view of verifying the principles which it develops by the study of thc^^^ 
great masters in painting and sculpture, the lamented author yisited the^^^ 
Continent in 1840 ; on his return he recoroposed the whole work for a new— ^^ 
edition, and was engaged in its final revision for the press immediatel) ^^ 
l)efi)re his death in 1842. 

Nearly the entire work has been re- written. What formed the inlit> ■*" 
ductory essay of the former editions, forms the eoncluding one of thia^^ef^ 
which commences with a comparison of ancient and modem art, and a-^^^ 
sketch of the influences under which the masters of the Italian school-^^"** 
studied and composed their great works. What may be called the formei -•" ^ 
work was more exclusively devoted to the relations of the subject to th e-*— ^ ^^ 
art of pMnting ; the present embraces a fuller analysis of the souxoes ot" - ^^ 
beauty and expression, and an examination of the theories of beauty in the ' ^=^ 
human countenance, and of ideal beauty. What was contained in the ^^=**^ 
former essays is mostly embodied in these, but extended and re-arranged ; '^c- > 
and the whole work is enriched by illustrations derived from various ^^* 
sources, and particularly from observations made upon the great works of *^^*- * 
art examined by the author during his continental tour. The work has ^^ 
been edited, apparently with much taste and judgment, by Mr Shaw, ^^ 
surgeon to the Middlesex Hospital, by whom an Appendix has been added '^^ 
containing a review of Sir C. Bell's opinions on the nervous system ; the "^ 
part of the last edition which related to that subject having been erased by " 
the author before he had produced a new essay to supply its place. 

In the present edition a considerable number of the sketches whidi 
illustrated the former ones are withheld. Although satisfied that this has 
been done with discrimination and taste, we can scarcely avoid regretting 
that they were not retained. Some of tiiem were certainly rather fimcifdl 
and overdrawn, but they were valuable as the realization, in some degree, 
of the ideas and principles of the writer, and bore the marks of that genius 
which was almost always perceptible alike in his writings and his sketches. 
The best of the engravings of the former editions, however, are all retained, 
a&d to these have been added several new vignette illustrations of great 
beauty and spirit. Of these we were particularly struck vrith the h^ of 
a child in p. 17, and the bust of a man in p. 162 ; — they are accurate in 
drawing, and full of expression and beauty. If we were inclined to be 



ANATOMY AND PHILOSOPHY OF EXPRESSION. 205 

hypercritical, some &iilt8 in drawing might he pointed out, a?, for instance, 
the outline of the forearm in the figure p. 210 ; hut it would he unjusti- 
fiable to criticise severely the posthumous work of one who undoubtedly, 
was no mean artist, and of whom our sad conviction is, that if he had sur- 
vived to see his favourite work re-published, it would have appeared with 
many embellishments, now for ever lost to the public, selected from the 
exquisite sketches made by him during his visit to Italy. 

The anatomy and philosophy of expression have relations to physiology, 
and to the duties of the practical physician, not less than to the fine £^. 
It is in this view, as well as because we .claim a peculiar interest in all the 
writings of so distinguished a member of the medical profession, that we 
notice a work of this kind in a journal of medical science. The aim and 
design of the author are not only to enforce the study of anatomy on the 
artist by pointuig out its advantage in drawing the human figure, but to 
investigate the sources of beauty and expression by an inquiry into their 
relation to the interior structure and functions of the body. 

Following our late distinguished townsman, the author of the " Essays 
on the Nature and Principles of Taste," Sir Charles Bell traces the beauty 
of the human countenance to the association of ideas — to the capacity for 
expression, or the emotions or thoughts of which it is expressive. 

" A face," he observes with much truth, " may be beautiful in sleep, 
and a statue without expression may be highly beautiful. On the other 
hand, expression may give charm to a face the most ordinary. Hence it 
appears, that our inquiry divides itself into the permanent form of the head 
and face, and the motion of the features, or expression. 

^ But it will be said there is expression in the sleeping figure or in the 
statue. Is it not that we see in these the capacity for expression — that our 
minds are active in imagining what may be the emotions of these features 
when awake or animated \ Thus, we speak of an expressive face before we 
have seen a movement, grave or cheerful, or any indication in the features 
of what prevails in the heart." * * ♦ « a. countenance may be distin- 
guished by being expressive of thought, that is, it may indicate the posses- 
sion of the intellectual powers. It is manly, it is human ; and yet not a 
motion is seen to show what feeling or sentiment prevails. On the other 
hand, there may be a movement of the features, and the quality of thought, 
— afi^ion, love, joy, sorrow, gratitude, or sympathy with suffering, — ^is 
immediately declared. A countenance which, in ordinary conditions, has 
nothing remarkable, may become beautiful in expression. It is expression 
which raises affection, which dwells pleasantly or painfully on the memory. 
When we look forward to the meeting with those we love, it is the illumi- 
nated face we hurry to meet ; and none who have lost a friend but must 
acknowledge that it is the evanescent expression, more than the permanent 
form, which is painfully dear to them." Pp. 20, 21. 

In the examination of the relative proportions of the cranium and face, 
some curious foots are pointed out, not generally recognised by anatomists 
or artists. The idea is generally entertained, that in the different varieties 
of mankind the development of the cranium bears an inverse ratio to that 
of the &ce ; that as the capacity of the cranium diminishes, that of the face 
increases, and vice versa ; that the cranium grows as it were at the expense 
of the fece. Sir Charles Bell here shows, by reference to experiment, 
that, on the contrary, the negro face, e,g.y is actually smaller than the 
European, considered in relation to the cranium (p. 38), and that the 
apparent difference and real distinction between them, besides the difference 



JJ06 ANATOMY AND PHILOSOPHY OF EXPRESSION. 

of abaolttte size of the cranium^ is in the greater development in the n^gro, 
not of the whole face, but of the parts immediately concerned in maHication 
alone. 

The imperfection of the facial angle of Camper as a means of determin- 
ing the relative dimensions of the cranium and £ace is acknowledged ; not 
sOy perhaps, the idea that this angle, if increased to a right angle or an angle 
of 90% fails to confer on the face the beauty or grandeur of the antique. 

** Camper's position is this, — ^that as by the diminution of the cranium 
and the further inclination of the facial line the head is depressed in char- 
acter to that of the negro ; so, by raising and throwing the skull upwards 
and forwards, untU the facial Ihie reaches the perpendicular, as in the pre- 
ceding page (referring to a sketch of a very beautiful Mercury from the 
antique), the great object is attained of resemblance to the antique head. 
But Ids own figures contradict his conclusion ; for although he has 
thrown the head forward in them, even beyond the perpendicular of the 
facial line, yet, as he has preserved the features of common nature, we 
refuse to acknowledge their similarity to the beautiful forms of the antique 
marbles. It is true that, by advancing the forehead, it is raised ; the face 
is shortened, and the eye brought to the centre of the head. But with all 
this, there is much wanting, — ^that which measurement or a mere line will 
not show us." Pp. 28, 29. 

Our author accordingly traces the source of beauty in the antique 
statues to the delineation of those features which are associated in our 
minds with the possession of the nobler feelings and higher intellectual 
qualities of our nature. As speech is one of the greatest marks of dis- 
tinction between man and brutes, so the greater or less development 
and adaptation of those organs which are designed for the use of that 
faculty is peculiarly associated with manly beauty. The adaptation of 
the lips for articulation and expression, of the nose and frontal anuses 
for the manliness of the voice, and not their nze, distinguish those organs 
from the purely wvuual oigans of the lower animals. So of the eye 
and ear. 

Discarding altogether the belief in the existence of such an abstraction as 
that of an ideal beauty, or of any notion of divinity other than can be de- 
rived from the contemplation of humanity^ Sir Charles contends that tiie 
representations of divinity of the ancient sculptors owe their grandeur to 
the exaggeratioiii of those features which are by us associated with the nobler 
qualities of mind ; and that the ideal beauty of the ancient masters in 
painting was arrived at by the delineation of those features which are asso- 
ciated with the pleasing emotions and purer virtues of the heart. 

** With the view of attaining beauty, the artist is not to slight nature or 
to avoid it^ but to study it deeply as the only source of Improvement. He 
must not only contemplate those beauties which we may suppose to stand 
before him, but consider where they differ from others leas admirable. How 
beautiful that smile I how eloquent those lips ! Let him ask Jiimylf in 
what this consists. Smiling and ^eech are chaiacteiistic of man, and are 
bestowed to express the affections of the heart and communicate thoughts. 
Give to the mouth the capacity for these. Observe the forehead and the 
defb&ed eyebrow ;^-'What is there in nature superior ! Let liSiw T^MM'k them, 
and then raise and throw forward the forehead, a feature especially hnwiim 
and elevatipg to the countenance. Now he sees that depth is given to the 
eye; that the shadows fiill with bold relief; the eyebrow acquires more 
freedom, stands in a finer arch, and is more expressive of agreeable emotions. 



ANATOMY AND PHILOSOPHY OF EXPRESSION. 207 

Aqd thus he passes froin point to point, — ^from one feature to another — ^the 
nose— the ear ; exaggerating a little the outline of whatever indicates the 
higher and purer qualities, and avoiding what is low, or whatever is asso- 
ciated with the baser human passiona or with the form of the brutes ; and 
by insensible gradations, and long contemplation of what is highest and best, 
he acquires from nature that idea which is in his mind the perfection of 
form." Pp. 68,69. 

In Essay IIL the author goes on to examine those sources of expression 
which cannot be explained on the idea of a direct influence of the mind 
upon the features ; and here he develop? and illustrates very beautifully his 
ideas regarding the muscles of respiration being in a peculiar manner the 
organs of expression. The mind actmg upon the heart, and that upon the 
ciitsulation through the lungs, produces all those uncontrollable signs of 
emotion which are the indications of human passion. " At the instant of 
our birth an association of muscles is formed, and at the same time put in 
operation, stamping a character of expression, which betrays the wants of 
the body in early infancy, and the suflFerings of the mind in the after- 
period. The frame of the body, constituted for the support of the vital 
fanctions, becomes the instrument of expression ; and an extensive class 
of passions, by influencing the heart, — ^by affecting that sensibility which 
governs the muscles of respiration, calls them into operation, so that they 
become an undeviating and sure sign of certain states or conditions of the 
mmd. They are the organs of expression." 

" Returning now to the contemplation of any of the stronger passions, we 
comprehend much which was before obscure. We see why that grief which 
strikes the heart should affect the regularity of breathing ; — why the muscles 
of the throat should be affected with spasm ; — why slight quivering mo- 
tions pass from time to time over the face, the lips, and cheeks, and 
nostrils ; — ^because these are the organs of respiration, — organs which have 
their muscles united to the sensibility of the heart, and moved under its 
influence. Now we comprehend how the passion of rage or terror binds 
and tightens the chest, — ^how the features are so singularly agitated by the 
indirect as well as by the direct influence of the passions, — how the words 
are cut, — ^how the voice sticks in the throat, — how the paralysed lips refuse 
the commands of the will, so that they are held in a mixed state of violence 
and weakness, which, more than any flxed expression, characterizes the 
inflaence of the passion." Pp. 94, 95. 

The two following essays are devoted to a description of the muscles of 
the face in man, and a comparison of them with those of the lower 
animals. Admirable and accurate as the remarks generally are on the 
actions and uses of the various muscles of the face, we cannot refrain 
from remarking, that the descriptions of them are far from being suf- 
ficiently full and minute for a work specially devoted to this subject ; 
nor are the wood-cuts which accompany the letter-press calculated to 
supply the defect by giving accurate delineations of the muscles. Nor 
have we ever been able to understand how the action of the oblique 
muscles of the eyeball has been made to contribute to the support of the 
so-called respiratory system of nerves. Neither the superior oblique 
muscle alone, which is supplied by the pathetic nerve, nor the two oblique 
acting conjointly, could ever produce those *• upward glancings of the 
eye," which are referred to them, and to the influence of the respiratory 
nerves. 

We are hardly prepared, either, to disinherit the lower animals of all 



208 ANATOMY AND PHILOSOPHY OF EXPRESSION. 

but instinctive emotions. Although less expressive than the ^'haman &ce 
divine," we are strongly prejudiced with the belief that they have their 
feelings and emotions as well as ourselves, and that their faces possess, if 
we fully understood and studied the index, the means and capacity of ex- 
pressing them. 

Of the essays which follow^ on the expression of the various passions, 
of expression in reference to the body, of the study of anatomy as neces- 
sary to design, and of the uses of anatomy to the painter, we cannot ex- 
press ourselves in terms of too high commendation. They are characterized, 
with some &ults of recapitulation and want of system, by great beauty 
and truthfulness ; — they display the nice discrimination and taste of the 
artist, the feeling and sympathies of the man of genius, and the reflection 
of the philosopher. Interesting as they must be, and truly valuable to the 
painter and sculptor who would make nature his study, a perusal of the 
observations cannot fail to interest the physiologist, and to benefit the 
physician. Such habits of observation and reflection as they are calculated 
to inspire would prove of infinite service in the detection and diagnosis of 
disease, — in the acquisition of that nicer tact — ^the vUus erudUus — ^which 
is or ought to be the peculiar characteristic of the accomplished physician. 



1. Bemarks on Schools of Instruction for Military and NawU Surgeons^ in a 
Letter to the Right Hon. Sir Robert Peel. By Sir George Ballingall, 
Regius Professor of Military Surgery in the University of Edinburgh. 
1843.— 2. Catalogue of the Museum attached to the Class of MiUtary Sur- 
gery in the University of Edinburgh. 1844. 

It requires but a very superficial acquaintance with the history of mili^ 
tary campaigns and naval expeditions to discover how much their success 
depends on efi^ctive measures being adopted to preserve and restore the 
health of the forces employed. Nor can such measures be always alike ; 
they must be varied with the varying circumstances of warfare. It is true, 
the care of the health of armies and fleets ultimately rests on the great 
rules applicable to diseases and injuries in civil life. But there must be a 
great amount of practical knowledge, to be acquired only from the reports 
of those who have been in actual service, requisite for carrying those rules 
into efipect with the best advantage in circumstances so difierent from those 
under which medicine is practised at home. To collect, arrange, and teach 
this description of knowledge is the peculiar object of the medicine of fleets 
and armies, generally known by the restricted name of Military Surgery. 

There never was a country so situated as to have stronger claims on it for 
the encouragement of this branch of medical study than the United King- 
dom. True, we enjoy the blessing of peace ; but we firmly believe we shall 
never retain that blessing otherwise than by being armed cap-a-pie for war. 
By well-appointed armies and fleets we obtained peace, and by nothing less 
can it be maintained. But our colonies and distant possessions aflbrd nearly 
the same room for the exercise of fleet and army medicine, so to speak, as if 
we were engaged in actual war. Our soldiers and sailors are exposed on 
distant shores to unusual vicissitudes of temperature and climate, — to the 
burning sun and drenching rains of tropical countries, — ^to ever- varying epi- 
demic influences, — to marsh eflluvia, — ^to confinement on shipboard in tedious 
voyages ; and are therefore at all times nearly as liable to those scouiges of the 



MILITARY AND NAVAL MEDICAL SCHOOLS. 209 

camp-fever, ague, dysentery, cholera, &c. — as in war time. The hospital* 
service in the British army and navy may be as severe in time of peace as 
in time of war. The newly appointed hospital mate^. trained merely in the 
ordinary schools, may know how to treat gun-shot wounds without any 
material error ; — ^yet even here not less skilfully because he has listened to 
the instructions of one who has been familiarly conversant with such acci- 
dents, or whose collections of their effects^ in the form of preparations, 
enable him to show the main points in which the treatment of some of them 
deviates from the rules applicable to the same kinds of injury otherwise 
prodoced ; — ^but to all that concerns the peculiarities of an army surgeon's 
duties^ — ^the- direction of hospitals, the moral treatment of a class of men to 
whose habits, modes of thinking, and contrivances for deception and the 
like, he must be an utter stranger, — ^not knowing even where to seek for 
information, if his education lias been confined to the walk in which those 
designed for practice at home study. No doubt the hospital mate soon gets 
into the routine of the service ; but if that routine has sprung up under the 
mere force of circumstances constantly changing, what chance is there that 
it is as well founded as it might be, did it rest on the well-considered plans 
of men chosen for their experience and ability to superintend such instruct 
tion, and who would necessarily check each other's peculiarities and errors 
of judgment by a free intercommunication of knowledge ! The division of 
labour has worked wonders in many departments of human knowledge ; 
and there is no reason to doubt that its effects might be made as conspicu- 
QUS in fleet and army medicine as in any other department. 

These reflections have been suggested to us by the perusal of Sir G. 
BalUngaH's letter, addressed to Sir R. Peel, on schools of instruction for 
military and naval surgeons. Sir George's object is to show the expediency 
of establishing a professorship of military surgery in the two other metro- 
politan cities as well as in Edinburgh. Our limits prevent us from extract- 
ing any part of this letter, which is the less necessary, because Sir G.'s views 
sufficiently appear in his reply to the strictures in the Medico- Chirui^cal 
Review on his letter. This reply will be found stitched up with our present 
number at the end, and to it we beg to call the attention of our readers. 

Among the other praiseworthy exertions of Sir Geoi-ge to promote the 
object of the chair which he fills, is the foundation of an illustrative museum. 
We have before us a catalogue of that museum recently printed, and an in- 
spection of the museum itself has gratified us very much. The university 
has lately enabled Sir George to make a large addition to it. There is 
much in it to interest medical officers in the public service, bearing on va- 
rious departments of their duties ; but what gives a particular value to the 
museum is a collection of considerably upwards of a hundred preparations, 
made literally on the field of battle by Mr Rutherford Alcock, during the 
service of the British Legion in Spain. 

. There are thirteen preparations showing the efiect of musket balls, frag- 
ments of shells, &c., on the bones of the head and the dura mater ; seven 
showing the effects of the same on the vertebrte and ribs ; three on the > 

bones of the pelvis ; eleven on the bones and joints of the upper extremity ; 
forty-five on those of the lower extremity ; besides many others in illustra^ 
tion of the effects on the boneJs of amputation, exfoliation, exostosis, &c. 
Several preparations show the efiects of gun-shot wounds on the bmin and 
nerves^ others the effects of the same on the thoracic and abdominal viscera, 
others on the blood-vessels. Altogether this part of the museum appears 
to us to be unique, and calculated to be of the greatest practical use. We 

2» 



t 



210 APPLICATION OF PRISMATIC REFLECTION 

have heard of nothing to be compared to it elsewhere. We trust the xix^d 
cal officers of the army and navy will second Sir Greoi*ge's efforts, an<i ^^ 
to this interesting collection a» opportunities offer. 



On the Application of** Prismatic Reflection " to the Investigation o/DU^^ 
situated in the Open Cavities of the Body, By Dr Warden, F.Er.C. S. ^E^ 
Edinburgh. 

Much difficulty has hitherto existed amongst the profession generally^ in 
the obtaining of a satisfactory, simple, and generally useful method £cyr 
aiding them in the investigation and diagnosis of the diseases affecting tlie 
deeper seated parts of the open cavities of the body ; and though the prin- 
ciple and means here proposed may not, in every instance, fully realize our 
expectations, yet the principle is by far the most simple and elegant of any 
that has heretofore been applied. The means recommended for effecting' 
this purpose are based on the principle of illumination by means of totally 
reflecting prisms of flint glass. 

These prisms are fitted on a speculum adapted to the cavity which it is 
desirable to explore, and the direct sun's rays, or even those from an un- 
shaded side-light, falling upon one plane of the prism, become totally 
reflected by the other, and are transmitted along the centre of the speculum. 
Dr Warden particularly notices its application to the investigations of the 
morbid conditions of the auditory passage, and for which he has also de- 
vised an instrument. " It is formed," says he, " with the view of ^ts 
being adapted not only to the different development of the organs of hear- 
ing in youth and age, but also so as to form a series of dilators, applicable to 
the removal of strictures, upon the same principle as regulates the treat- 
ment of the same disease in other situations." 

** The instrument devised and represented in the accompanying diagram 
consists of a straight handle, a a, five inches in length, terminating i^ * 
ring, 6, of half an inch internal diameter, the ring grooved in its interior *8 
a screw. To this screw are adapted four canulae or straight tubes, c, of four, 
three, two, and one lines calibre, and another, d, of a funnel or tapering 
shape, applicable for preliminary exploration, and removal of any accum^" 
lated cerumen obstructing the passage of the light, also for affording a p^^ 
per field for the passage of instruments, and other topical manipulation* 
From the middle of the straight handle arises a curved branch, c, moveal>l® 
in a pivot joint at/, toward either side of the handle. This branch fort»8 
a stidk on which a prism of flint glass, g, is perched erect, to the level of 
the opening of the affixed canula. The prism rests in a metallic socket, 
and is made to revolve on its own axis at the touch of the finger, or to ^* 
main fixed in any desired position, by the aid of a small clamping screw, *• 
The instrument is thus complete for use. The canula is to be introduced 
into the ear to be examined, the patient being seated, exposed to a goO" 
light. The surgeon placing himself conveniently opposite to the side of the 
patient, a face of the prism is turned towards the light, and it is made t^ 
revolve until the luminous spectrum is conveyed to the bottom of the canul^ 
and to the surface sought to be observed. There is no difficulty in tn® 
adjustment of the position when the new relations of the light and of th« 
object are familiarized by a little experience ; and when once this adjust- 
ment is made, the full and clear illumination of the object is at once ob- 



TO THE INVESTIGATION OF DISEASES, 
PRISMATIC AURI800PE. 



211 




212 APPLICATION OF PRISMATIC REFLECTION 

tained, and with a degree of brilliancy exactly proportioned to the quar^ -tity 
of light employed in the particular observation. 

" The principle or theory consists in total reflection : the light is received 
by one side of the prism, is reflected from the second side, and emeiges by 
the third side to the object illuminated, as represented by the dotted lines 
O! y as, and whence its View is revealed to the eye. The illumination is not 
preternatural or dazzling, such as would alter the real features of dise-ase, 
but natural, and such as the eye is familiar with. The advantage of -fchis 
flat natural light will be fully appreciated by professional eyes ; and I «in 
persuaded, from ample experiment, that any means of concentrating 1 ight 
by lenses, or converging mhroiTS substituted for the prism, would not im- 
prove the serviceableness of the instrument exhibited, although by iJieir 
subsidiary employment they may be made to contribute to its efficiency, 
whenever, under extraordinary circumstances, more intense L'ght isi re- 
quired. 

" The method of illuminating diseased parts by the medium of the prism 
is relieved from the intricacies inseparable from the employment of a 
reflecting speculum, whose curve must be anew adapted by the manufacturer 
to the focal distance of the object to be viewed, otherwise it is indistinct 
and distorted, as in a false mirror. Neither is the method invented by me 
liable to the objections applicable to various ingenious contrivances for the 
same end, which we owe to distinguished members of the profession. By 
the convenient position of the light in prismatic illumination, it is not 
liable to be intercepted by the sliadow of the observer, as is the case with 
any direct light proceeding from behind him, — a disadvantage we are not 
free from even where sunlight is employed ; and if a lamp and lens be 
placed between the eye and the object viewed, not only does the dazzling 
artificial medium alter the characteristic aspect of disease, but such appara- 
tus, in order to guide any surgical procedure, must be kept strictly in such 
a position as necessarily to interfere with any convenient measures in the 
removal of foreign bodies, or other manual operations. By a construction 
of instmment suited to the situations of disease in the different cavities, 
increased facilities in surgical practice, I feel warranted in asserting, are 
largely attainable through the adoption of the method proposed by me. 

** I may mention also, that I have satisfied myself by varied experiments 
that a totally reflecting prism placed in the angle of a bent canula, and 
illuminated by a second prism, in the manner already described, i^vill afford 
a satisfactory view of objects whose situation precludes the possibility of 
direct observation — ^such as the opening of the Eustachian tube and of the 
glottis, the position of foreign bodies detained in the throat, &c. For the 
sake of illustration I may state, that by a simple arrangement, consisting 
of two tubes, each twelve inches long and one inch diameter, embracmg 
at their point of junction, at right angles* to each other, a right-angle<* 
prism, I have been enabled to make inspection with the utmost accuracy 
of exquisitely coloured drawings of the morbid anatomy of the eye ; ob- 
taining by the arrangement described a reflection of the image presented 
at the opposite extremity of such an instrumentj and that in all the bril- 
liancy of sunlight view. 

** Furthermore, I find that a diseased surface can be accurately inspected 
at the extremity of a straight tube of twelve inches long and a quarter of 
an inch diameter ; and I indulge the hope, that within this range a more 
satisfactory treatment of highly seated strictures and diseases of the straight 
|[Ut, as well as of diseases of the urinary organs, may be thereby attained* 



i'O THE 1N*VESTIGAT10N OF lilSEASES. 213 

That the latter expectation is not altogether visionary may be inferred 
from the fact, that the straight canula of the brisepierre of Baron Heurte- 
loup has a diameter of one-third of an inch." — Medical Gazette^ May 24, 
1844. 

Of the great utility of the application of the principle of prismatic re- 
flection and illumination, as above proposed by Dr Warden, there can be 
no doubt ; but as to the construction of the instrumental part of his 
auriscope, we do not think it calculated to be so generally useful. In cases 
of impaction in the meatus of any foreign substance, or when a polypoid 
growth is to be removed from the deeper portions of this tube, we do not 
think it could be used so advantageously as the common funnel-shaped and 
double-handled speculum of Kramer. If, therefore, the prism weie to be 
mounted on this latter form of instrument, it would £EicUitate, more than 
at present enjoyed, tlie application and advantages either of natural or of 
artificial illumination. We consider that the most important advantage 
gained to the practitioner by the use of prismatic reflection arises from the 
facility with which the recesses of the open cavities of the body can be affected 
by means of a side light. This facility holds good in whatever cavity the 
illumination may be required ; and Uius the interposition of an artificial 
lamp between the eye of the examiner and the tube of the speculum being 
avoided, his eye will be less obscured, as also less dazzled, and, what is of 
still greater importance, one of his hands will be at liberty, so as to perform 
without the aid of an assistant any further examination or operation, if 
required. The profession are certainly deeply indebted to Dr Warden for 
his ingenious, simple, and elegant application. 



ANALYTICAL CHEMISTRY. 

As there are few of our professional readers, especially those in the 
country, who may not be called on at some time to execute chemical 
analyses, in cases of poisoning or the like, and as duties of this kind are 
certaui to devolve on the medical officers of the army and navy when on 
distant stations, we recommend to their notice the following treatises : — 

Eementary Instruction in Chemical Analysis, by Dr C. R. Fresenius, 
Chemical Assistant in the Laboratory of the University of Giessen. 
Edited by J. L. BulLogk. London, 1843. 

Elements of Chemical Analysis, Inoi^ganic and Organic, by E. A. Pabneli«, 
Chemical Assistant in University College, London. 1842. 

Traite .Pratique d' Analyse Chimique, par Henri Rose, traduit de 
r Allemand sur la quatrieme edition^ par A. J. L. Jourdan ; accompagn^ 
de Notes et Additions par E, Peligot. A Paris, 1843.— (A Practical 
Treatise on Chemical Analysis, by Henry Rose (of Berlin), translated 
from the fourth German edition, by A. J. L. Jourdan ; accompanied by 
Notes and Additions by E. Pelioot. Paris, 1843.) 

Dr Fresenius' work is an excellent treatise extensively employed in 
the practical chemistry sdiools of Germany, which we can reconmiend as 
of great value so far as it goes. It treats however solely of qualitative 
analysis, and the translation, though clear enough, is awkward and inelegant. 



214 ON THE STRUCTURE OF THE NERVOUS SYSTEM. 

Mr Pamell's treatise is in all respects the one best suited to most readers, 
as it is not more expensiye than the work of Fresenios^ and includes quauti- 
tative as well as quaUtatiye analysis. It is the most recent English work 
indeed on the former branch of the art, and contains the latest improve- 
ments up to the date of its publication. 

Rose's book is much ampler than either of the others, and is the ac- 
knowledged text-book of Europe in inorganic analytical chemistry. We 
haye an excellent English tramslation by GrifBn of the first German 
edition of 1829, but it is now nearly out of print, and the originai 
work has been increased by almost a third since the translation 
was made. The French translation being from the fourth Grerman edition, 
and furnished with notes from the well known chemist P^ligot, is much 
superior therefore to it. 



Part III— PERISCOPE. 



ANATOMY AND PHYSIOLOGY. 

On the Structure^ Relations, and Ftinctims of the Nervous System. 
[Continued from our last.] 

** Experiment 5. — ^The cord alone was divided in ihe fourteenth and also 
the twentieth segment, and the interyeniug portion was destroyed by 
breaking it down with a needle. The animal exhibited in the anterior part 
of its body all the evidences of perfect volition. It moved actively along, 
turning itself back on either side repeatedly, as if to examine the anterior 
wounded portion, which it felt again and again with its antemue, and when 
attempting to escape, frequently turned back as if in pain and aware of some 
hindrance to its movements, but it seemed perfectly unoonscioos of the 
existence of the posterior part of its body, behind Uie first incision. In 
those s^ments in which the cord was destroyed, the l^s were motionless, 
while those of the posterior division, behind the secoi^ indaion, were in 
constant but involnntaiy motion, the movements being similar to those of 
walking or running, uniformly continued, but without any consentaneous 
action with those of the anterior part, by which locomotion was performed, 
dragging the posterior divisions of the body after them. When the animal 
was held by the posterior segments, reflex actions were excited in the legs, 
and po werftil contractions and gyraUons of the whole animal weie peifonned 
in those s^;ments ; but these movements appeared to be entirely the result 
of reflex actions of the muscles, since exactly similar ones took place in the 
whole body in deccqpitated specimens. At the expiratkMi of iweive hours the 
most perfectly voluntaiy acts were performed by the head and anterior 
division of the body, such as locomotion forwards or to either side, avoidance 
of any obstacle, touching it with the antennc, which were in rapid action 
as in an uninjured animAl^ und attempting to readi and rlimli up an obstacle 
presented to it, but not in immediate contact with it. Bat reflex motions 
alone existed in the posterior divKskm, in which the legs were veiy slowly 
moved, even whan the animal was not progressing. B^sk actions were now 
more easily excited in them than at first, either by contact with the segments, 
by initation of one w two of the leg$ themselves^ or by a sudden cuient of 



ON THE STRUCTURE OF THE NERVOUS SYSTEM. 216 

air. By these means, when the animal was lying still, actions were imme- 
diately excited in all the legs of the posterior part of the body anterior and 
posterior to those which were irritated, and these actions were induced in 
those of both sides of the body, but appeared to commence on the opposite 
side, in the legs corresponding to those which were first irritated. In 
eighteen hours the anterior part of the body was quite dead, no motions 
whatever could be excited in it, either voluntary or reflex, but reflex actions 
were then readily excited in the posterior, and also slightly so by mechanical 
irritation, even at twenty-four hours." 

** Other experiments were now made on the brain itself without detaching 
the head of the animal from the body." 

** Experiment 6. — The brain was completely divided longitudinally in the 
centre by a fine pair of scissors. All power of recognising obj ects was imme- 
diately lost. The antennffi were perfectly motionless, and the animal at 
first moved directly forwards, as in the first and second experiments, 
dragging the antennse along with it at the sides of the head. It passed on 
with the head, first segment elevated, and climbed over every slight obstacle, 
and when opposed did not turn to the right or to the left, but passed forwards 
with the legs moving rapidly as in the act of running. At the expiration 
of half an hour it had regained a little of the power in the left antenna, and 
then constantly moved in a circle to the left side. When either antenna 
was pinched, a sudden convulsive movement was induced in the whole body, 
but the antenn© were not retracted when touched, as they always are by 
the uninjured animal. At the expiration of an hour, slight motion was 
regained in both antennae, but the movements to the left side were still con- 
tinued. The brain was now entirely destroyed by a needle. All power of 
vohtion, which seemed to have been partly restored, as well as the use of 
the antennee, were instantly lost, and the movements of the legs and body 
were precisely similar to those already seen in the decapitated specimens. 
Pinching the antenn® did not occasion the slightest convulsion of the body, 
or reflected movements of the legs, but slight pressure on the segments 
immediately induced them, and also violent contortions of the whole body, 
especially when applied to the anterior segments. In this specimen the re- 
flected movements were excited at the expiration of eighteen hours, but 
mostly so, at that time, at the posterior extremity of the body." 

« Experiment 7.— The brain was divided in the middle, and one lateral half 
with the antennal ganglion and optic nerve were removed. Some of the 
motions of the antenna of the unmjured side seemed to indicate the remams 
of volition. The animal coUed itself up and remained quiet as m health, 
but the posterior legs of the body were in constant motion. The power of 
recognising objects appeared almost entirel^^ destroyed. When the remam- 
ing lobe of the brain was irritated with the pomt of a needle, the body was 
agam extended and excited to slow progression forwards, exactly as m the 
preceding experiments, but the power of moving was very feeble. At the 
expiration of two hours, the specimen having remained undisturbed in the 
interval, slow progressive movements in a circle were induced by pressure 
on the segments, and always in the direction of the injured side, the left in 
this specimen." 

" Experiment S.—The lobe on the right side of the brain was removed, 
and the results were precisely similar to those of experiments 6 and 7, and 
the movements were to the righty the side injured m this specimen." 

« Experiment 9.— The right eye and optic gangUon were both destroyed by 
puncturing with a fine needle. The antenna of that side of the head became 



216 ON THE STRUCTURE OF THE NERVOUS SYSTEM; 

completely motionless, and perception of objects was destroyed ; but the 
animal still retained its voluntary powei's, and was able to recognise objects 
on the left side, on which the antenna and eye were uninjured, and seemed 
to a great degree to retain their powers." 

" Ejpperiment 10. — Both antennse were cut oflF close to the head, leaving the 
brain uninjured. All the powers of the animal continued perfectly volun- 
tary, and it sought or avoided objects as usual, but by means of the palpi and 
vision, with not the slightest indication of reflex movements. When the 
point of a needle was passed in at the antennse, the animal gave indications 
of great pain by its movements, but these were not reflex. When placed on 
the table it again sought objects, and carefully avoided falling over, by 
changing its course when it arrived at the edge. The brain was then destroy- 
ed through the insertion of the antenne, and the movements immediately be- 
came reflex, and soon ceased, except when they were artificially re-excited." 

** Experiment 1 1 . — The eyes on both sides of the head were removed without 
injuring the brain or antenns. Volition continued perfect, but the movements 
of the animal were slower, and all objects were explored with the antenn* ; 
and it avoided nothing except when in direct contact with it or when its 
presence had been ascertained by means of these organs. But immedmtely 
the needle was passed into the brain, all the motions became reflex, and 
precisely similar to those already detailed." 

" These experiments seem to lead to the conclusion that the seat of volition 
is solely in the supra cesophageal ganglia of these animals, since all direction 
of purpose, all avoidance of danger, all control over the movements of the 
body, either of speed or change of direction, are lost when these are much in- 
jured or removed. Volition quickly ceases when they are severely wounded, 
and is greatly diminished even when one only is slightly aflected. This latter 
fact is indicated by the loss or diminution of purpose, and by the gyratory 
movements of the body. The experiments seem also to show that sensation 
may remain after the injury or removal of one lobe of the brain, as was 
proved by the retraction of the antenna when slightly touched on the 
uninjured side of the head, and by the cleansing and excited act of drawing 
it constantly through the mandibles ; and further, that pain is felt when the 
cerebral lobes are injured, as when the needle was applied to them after the 
antennffi had been removed. They lead also to the conclusion, that all the 
phenomena which occur in the posterior parts of the body after the brain 
and cord have been separated are reflex or excited, and that these are most 
intense at the two extremities of the cord — the medulla oblongata, and the 
terminal ganglion ; and farther, that the reflex phenomena are always 
excited and do not occur spontaneously, and that their intensity is greater 
in proportion to the stimulus applied, and gradually diminishes until they 
entirely cease, or are re-excited, precisely as already shown by Dr Hall in 
the vertebrata." 

" These experiments seem farther to show, that the reflected movements 
cease first in the anterior part of the cord and its ganglia, and that they are 
retained longest in the posterior ; that the movements are most powerful 
and continue longest when the cord is entire, the brain alone being separated 
from it ; and that they entirely cease sooner in proportion to the greater 
number of parts into which the cord is separated : further, also, that the 
reflex phenomena are less readily excited in the anterior part of the cord, 
while it is still in connexion with the brain, and that they cease entirely 
soon after the cessation of volition in that organ, as in those experiments in 
which only a very short portion of cord was removed with it from the body," 



ON THE STRUCTURE OF THE NERVOUS SYSTEM. 2l7 

'* Many of the phenomena are precisely simUar to those which have here- 
tofoi'e been observed in the Crustacea. They agree in the circumstance 
that violent contractions of the segments and limbs, both anterior and pos 
terior to a ganglion^ are induced by irritation of that ganglion both when 
connected with the brain and when insulated from it, thus proving these 
movements in the latter instance to be reflex ; but there is as yet no direct 
fro^ that sensation does not also exist in these ganglia." 

'* The general results of these experiments tend to confirm the beL'ef that 
the fibres now pointed out in the composition of the cord and ganglia, and 
which cannot be traced to the brain, are those by which these movements 
are executed independently of that oigan ; and further also, that the reflex 
phenomena are most intense, most easily induced, and are of longest duration 
in those animals of low organization, in which the volume of brain bears the 
smallest proportion to that of the whole nervous system, in which also 
volition and sensation ai'e of small iunount, and which have the body formed 
of the greatest number of similar uniform parts or segments." 



SURGERY. 

Academy op Sciences, March 4, 1844. 

" Keratoplastie:* 

M. Feldmann presented to the academy a second memoir on Kdratoplastie 
(transplantation of the cornea), containing the results oi twenty keratoplas- 
tic experiments performed in the lab(»ratory of M. Flourens^ at the Gaiden 
of Plants. 

M. Feldmann announces, under the form of a general proposition, that . 

Keratoplastie is interesting in a physiological point of view, for it exhibits 
an example of animal engrafting {gr^e animale), by the transplantation of 
the cornea. 

It is also interesting in a practical point of view, for it has been twice 
performed on man. 

In addition, keratoplastie experiments present a favourable opportunity, 
on the one htmd, to our accustoming ourselves on the eyes of living beings 
to ocular operations in general ; and, on the other hand, they enable us to 
study, during the course of these experiments, in a very easy manner, a great 
number of ^e diseases of the eye, that is to say, inflammation in all its de- 
grees and in all its consequences. M. Feldmann then treats of the different 
questions connected with keratoplastie, viz. the transplantation, the trans- 
parency, the methods, the instruments, and the organic proeess (travail) of 
the reunion* 

The foUofwiii^ are the remarks of the author on the organic proeess of the 
reunion : — 

1. The uniofli of the feireign cornea with the eye the suhject of the ope- 
ration takes place either by the first <x by the second intention, or by these 
two methods at one and the same time. 

It takes place by the first intention when the edges of the eomee are in 
contact with one another, or when they are only separated from one anotl^er 
by a small space. In the second case a very well marked plastic exudation, 
furnished by the neighbouring parts, especially by the iris, takes place be- 
tween the corneal edges. 

It takes place by the second intention when the interval between the 
corneal edges is considerable. 

2e 



218 KERATOPLASTIE. 

2. The circiilation (vaseularisation) la established^ in the case of union by 
the first intention^ in the new cornea, in the following manner : — One or 
several tolerably laige vessels proceed from the bottom (fond) of the con- 
junctiva, and advance close to the edge of the foreign cornea ; having arrived 
there, these vessels propel the blood into the new cornea by forming in it 
new and visible vessels, or by filling the old vessels of the foreign cornea 
which had been hitherto invisible. It always happens that these vessels 
are at the commencement very minute, mere sanguineous threads (desfileU 
ganguins), and they come off from their parent trunk in the form of rays, 
or in an arborescent manner. These vessels begin by appearing in the bot- 
tom (/and) of the corneal substance, as if the main trunk plunged itself at 
first into the deepest part of the tissue to deposit there the first drops of 
blood. 

3. The transparency of the applied (new) cornea, which remains during 
the first days after the operation, disappears aiterwards. The cornea changes 
its colour in proportion as the vascukrity is developed in its tissue ; it fin- 
ishes in the end by becoming more or less opaque. 

4. The aqueous humour wliich had escaped during the operation is repro- 
duced very quickly, in such a way as to raise up and cause to project the 
cornea, which had remained flaccid in front of the globe of the eye since a 
short time after the operation. 

5. When a part of the cornea swims, so to speak, in the pus which is 
secreted by the exposed (mUes d nu) neighbouring parts, and when at the 
same time the eyelids, especially their edges, exercise a slight abnormal 
friction on the cornea, it softens, and loses eaidly its conjunctiva. In that 
case there is no &rther method by which this cornea, deprived of its con- 
junctiva and softened by the pus, can undergo the process of reunion. 

6. The comea really transparent, finishes by becoming smaller on account 
of the absorption of the half or more of its siuface, and by becoming some- 
times flat, at other times convex. The points of cicatrization are adherent 
to the ins.—^azette Medicale, Mars 9, 1844. 



MATERIA MEDICA AND DIETETICS. 

On Skate-Liver Oil, 

We abridge some passages of a memoir by Gobley (Journal de Phantiaeie, 
Avril 1844) on the skate-liver oil. 

1. The skate-liver oil is much less offensive to the sights the taste, and 
the smell, than the cod-liver oil. The cod-liver oil is almost always turbid, 
brown coloured, and of a disgusting smell and taste ; while the skate-liver 
oil is quite transparent, is of a golden yellow colour, and has a weak fishy 
smell, and a taste by no means disagreeable.* 

2. The skate-liver oil contains more iodine than the cod-liver oil. 

3. That the skate-liver oil may be prepared by druggists, and thus that 
the doubts arising from the uncertainty of the source of the cod-liver oil of 
commerce may be avoided. 

Further, M. Gobley thinks, that by his process skate-liver oil may be 

* We have seen apedmeni of oil, dedared to be eod-liver oil, fivm ZetUmd, which 
agree with this account of the skate-liver oil Mr Pereira states the suggestion of 
a dealer, that the pale cod-liver oil of the German druggists must be the Southern 
whale-oi]..Mat. Alcd. vol ii. p. 1386L 



SKATE-LIVER OIL. 219 

prepared at a cheaper rate than cod-liver oil. Skate-lirer oil is commonl/ 
msAfi by boiling the liyers in water, decanting the oil which collects on the 
top, and clarifying it by rest and fresh decantations. M. Gobley's method 
is first to remove the membranes from the livers, to slice them thin, and 
then to heat them in a vessel (without water, as we interpret his directions), 
with constant stirring, until the contents boil ; the boiling is kept up at a 
moderate heat until the oil swims on the sur&ce quite detached from the 
clots formed by the rest of the substances ; the whole is then thrown on a 
piece of flannel, and when the chief part of the oil has passed through, the 
remaining mass is pressed against the flannel with a spatula, and left to . 
drop for twenty-four hours. 

** Oil thus obtained," he says, *^ does not retain water : it is left to itself 
for some days to allow it to deposit a certain quantity of white concrete 
matter ; when it ceases to deposit this matter, it is passed through filtering 
paper and laid by for use. The liver of the skate afibrds more than a 
fourth part of its weight of filtered oil." 

When a drop of concentrated sulphuric acid is added to fifteen of oil pre- 
pared in this manner, a fine violet colour immediately appears, which iSter 
a time passes to red. Wlien the oil is prepared by boiling the liver in 
water, the colour given by that acid is red from, the first. 

M. Gobley goes on to say, that the oil obtained by his process has been 
employed in the practice of Professor Trousseau, and that the efiects mani- 
fested were at least equal to those afibrded by the brown-coloured cod-liver 
oil. Our author thinks it likely that the cod and skate liver oils, besides 
iodine, contain phosphorus, which, according to him, would explain their 
miraculous efiects in rachitis. He has hitherto fiEiiled to detect it ; but he 
is not discouraged, and is resolved to persevere in the investigation. 



PATHOLOGY AND PRACTICE OF MEDICINE. 
Elephantiasis in Norway. 

M. Danielssen, physician to the St George Hospital, Beigen, has trans- 
mitted to the Academy of Sciences of Paris a memoir on the Elephantiasis 
of the Greeks, which has prevailed epidemically on the coast of Norway for 
half a century. This malady seems to rage with great intensity in Nor- 
way, for we find that out of 200,000 inhabitants, 1200 were attacked. In 
the great majority of dissections which were performed, M. D. found in 
the cutis vera, as well as in the subcutaneous cellular tissue, a hard gran- 
ular yellowish substance, which appears to have destroyed the tissues in 
which it was seated. The same substance was also found in the coats of 
the subcutaneous veins, to such an extent as, in the basilic vein for in- 
stance, to equal the thickness of the finger. Similar infiltrations were 
found in the eyes, the larynx, the trachea, the bronchi, the pleura, the 
liver, the spleen, the womb, the intestines, but, strange to say, seldom or 
never in the lungs. The treatment is unsatisfactory : once developed, it 
usually is fatal. 

[This disease, from the description given by M. D., appears to us to be 
Elephantiasis Arabum, and not Elephantiasis Griecorum, as he terms it. The 
Grecian elephantiasis, lepra taurica or Mai rouge de Cayenne, is in fact the 
leprosy of the middle ages, which we find first denominated by Lucretiua 
'* Est elephas morbus qui propter flumina Nili." Galen also fixes upon 
Alexandria as peculiarly the seat of its ravages (De Art. Curat, ad Glau- 
conem, lib. ii.) ; but this is a disease distmct both in its nature and appear- 



220 ELEPHANTIASIS IN NORWAY. 

ance from the E. Arabum. Arabian elephantiasis never commences primarilj 
in the skin, which the Greek elephantiasis always does ; and the latter is now 
seldom seen except in natives of the tropics, or those who have lived in 
some intertropical country. The results found on dissection by M. D. 
correspond with those usually observed in £. Arabum. 

Mr Chevalier (Med. Chir. Trans., vol. xi.) found the cellular tissue in- 
durated, and the papille of the skin enlarged, thickened, and projecting 
from the surface. The epidermis is generally thickened and furrowed ; 
the rete mucosum consists of several thickened layers ; the cutis vera 
often half an inch thick ; the cellular tissue the seat of a semi-gelatinous 
effusion (Andral, Arch. Gen. de Med. 1827 ; ib. 1823). The arteries sup- 
plying the afiected part have been found increased (Hendy) ; as was also 
the tibial nerve (Naegle) ; and in one case the great sciatic was much en- 
lai^d. We have not been able to find the deposition of the morbid matter 
in internal organs mentioned by any previous author, and are inclined to 
regai'd this as an interesting peculiarity in the cases observed by M. D.] 



Case of Ekphanti(u%» Cured by Guaiac and Iodine, By M. Cazenave. 
The disease was of eight years' standing ; the limb resembled a solid, hard, 
fleshy cblumn. 

The patient was ordered a strong decoction of guaiac and mezereon ; the leg 
was carefully bandaged fix)m the toes, and every other day the bandages were 
removed, and vapour douches applied to the surface, and an ointment of 
hydriodate of potass rubbed in. She was put on generous diet and wine, 
and confined to bed. The cure was efiected in little more than three months. 
This is not the first cure M. C. has met with by this plan, and several other 
cases have been benefited. [Mr Bui^ess cured a case by the internal use 
of iodide of iron, and the external application of the vapour of sulphur 
and iodine.] 



Cryptogami of the Hair constituting Herpes Tonsurans (JRingworm), 

M. Grubt communicated to the Academy of Sciences a memoir on the 
above subject, of which the following is the analysis : — 

Among the diseases of the scalp there is one which, by its contagious na- 
ture and the obstinacy with which it resists treatment, is deserving of the 
attention of the pathologist. It is the tinea tondens of M. Mahon, or the 
herpes tonsurans of M. Cazenave. 

Tinea tondens is principally a disease of the scalp, and is eharaeterized by 
the fidling of the hair in circular patches, covered with onall white scales, 
and with slight ineqtialities analogous to what is vulgarly called chicken 
flesh. On examining attentively, under the microscope, the fragments of 
hair coming from one of these patches, it becomes evident that their entire 
tissue is filled with ciyptogami, and that the hairs are still covered with the 
epidermic scales when their interior is already fiill of spomles. These 
cryptogami originate in the interior of the root of the hair, under the form 
of a group of round sporules. As the hair grows^ the cryptogami which it 
contains also grow, until it escapes firom its follicle. 

The cryptogami which constitute tinea tondens difier so much from those 
which contitute phytoalopecia (porrigo decalvans) that these diseases cannot 
be confounded. Their seat, their development, and the relation which they 
present with the tissue of the hairs, are quite distinct from what occurs in 
the latter disease. The cryptogami of tinea tondens are only formed of 



DR OLDHAM ON POLYPUS UTERI. 221 

sponilesand chaplets ; it is very geldom that we meet with elongated qK>nilefl 
imitatiDg branches. The cryptogami of phytoalopecia, on the contrary, 
present numeroos branches, curved, nndulated, the sporules being placed oti 
the side. In tinea tonsurans the sporules are large (diameter equal to 2 to 
6-lOOOth of a millimetre). The sporules of the cryptogami of phytoalopecia, 
on the contrary, are very small ; their diameter is only 1 to 5-1 000th of a 
millimetre. In tinea tonsurans the sporules fill the interior of the hairs, 
whilst their external surface is but slightly altered. On the contrary, the 
sporules of the mtcrosporon Oduini are placed on the external surface of 
the hairs, and form quite a sheath around them. Th« ciyptogami of tinea 
tonsurans originate and develop themselves in the root of the hairs. The 
microsporon Oduini, on the contrary, develop themselves on the external 
sur&ce of the hairs, outside of the follicles. These characters are so invari- 
able in tinea tonsurans that there is not a single diseased liair which does 
not present them. 



MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN. 

Dr Oldham on Polypus Uteri arid iU Coexistence toith Pregnancy. 

Dr Oldham's communication on Polypi* is one of far greater importance 
than the author's fanciful and novel definition led us at first to consider it. 
Although we cannot but commend the industry displayed by Dr Oldham 
in examining the structure of these growths, yet, as our main object is to 
furnish our readers with valuable practical information, we shall merely 
enumerate, very briefly, his remarks regarding their.situation and anatomi- 
cal character. The^r*^ variety is described as a fibrous, pediculated tumour, 
of frequent occurrence, assuming all shapes and sizes, originating from all 
the regions of the uterus, but most frequently from its fundus, body, or 
sides ; sometimes covered by the deeper tissues of the organ, at other times 
merely by its mucous membrane ; their vascularity residing essentially in 
their uterine covering, the arteries being insignificant compared to the 
great size of the veins, which do not appear, from the result of injections, 
to enter into the growth, though the arteries seem to do so freely ; they are 
tardy in their descent or in acquiring a pedicle ; may destroy the patient by 
hemorrhage, or by a clear watery discharge so copious as to saturate two sheets 
in the course of twenty-four hours, as happened in a case described by the 
author. Dr 0. informs us, that the uterus, not from its own weight, as was 
at one time supposed, but rather in consequence of its action to force down 
its contents, becomes partially inverted, which should be remembered in 
noosing the polypus, lest the ligature might be applied too near its radix 
and include the uterine tissue, which might, and we suspect often has, led 
to fatal results. The writer concurs in the views of the late M. Dupuytren, 
who maintained that a polypus which had lain long in the vagina had a 
tendency to undergo a cancerous degeneration, in some instances by a 
transformation of the growth into a cerebriform matter, and in others by the 
generation, as in this case, of fungoid patches, with softening of their struc- 
ture. In support of these latter sentiments, Dr Oldham adds the particu- 
lars of a case which occurred about two years ago in St Bartholomew's 
Hospital. Here an excrescence, the size of an orange, was noosed and 
tightened without pain ; but during the night straining efforts supervened, 
and forced into the vagina a mass of the magnitude of a calf's heart, on 
which a ligature was also placed and tightened every twelve hours. On 

• Guy's Hospital Reports, April 1844. 



222 DR OLDHAM OX POLYPUS UTERr. 

the second or third day alter this step, profase hemorrhage, owing to the 
rupture of a laige vein, commenced, which ultimately required the bleed- 
ing vessel to be secured. Rapid decomposition now followed, attended by 
an effluvium so offensive as to require the removal of portions of the mass 
by the knife and the use of the chloride of lime. The remainder of the 
polypus was detached on the fourteenth day, and the patient had a com- 
plete recovery. The malignant conversion insisted on by the late M. 
Dupuytren, and acquiesced in by Dr Oldham, does not invariably happen, 
for we have seen two polypi of immense size, which had for several years 
been lodged in the vagina without undei^ing the change referred to. 

The second vaHety of polypus described, is what has been styled spongy, 
cellular, or fibro-cellular : it may grow from any part of the womb ; it is 
softer and more impressible at the commencement than the variety already 
described. Sometimes, instead of descending to the os uteri, it ascends towards 
the fundus of the organ. On examining its structure, void spaces or cells 
are displayed, which the writer considers as truncated and divided veins. 
The present differs also from the foregoing variety in as far as that the 
veins are freely distributed throughout its substance. When associated by 
pregnancy, it may acquire so large a size as to weigh several pounds. Several 
illustrative examples are added, to which we shall presently advert. 

A third variety of polypus particularized, is one composed of a number of 
little cells, the size of the Graafian vesicle, with thin walls, filled with a 
pellucid fluid, supported by a fibrous tissue, about the size of a Brazil-nut, 
growing from the body of the terns, and furnished with a short pedicle. 

A fourth variety is furnished by an enlargement of the crypts of the 
cervix uteri ; they are sometimes several in number, vascular, filled with 
a curdy fluid, covered with a cortical layer of fibrous tissue, and about the 
size of a walnut. 

Dr Oldham describes a fifth variety not previously particularized. It 
arises from the cervix uteri, and from its interior exhibiting numerous large 
channels, he styles it channelled polypus of the cervix. The hemorrhage 
attendant on these growths is satisfactorily proved by the writer to arise, 
not from the uterine vessels, but from the veins of the excrescence, or of 
those of its investing mucous membrane. 

In the latter part of this communication, which is highly interesting, the 
writer informs us tliat the presence of a polypus will not prevent pregnancy, 
a fact with which we presume the profession have long been familiar ; and 
in corroboration of which a number of most important cases are added. 
Hera Dr Oldham suggests the very necessary precaution, before interfering 
with small polypi of the os and cervix, of ascertaining whether or not the 
patient be pr^nant, a state which might not be suspected, owing to the 
presence of disease and the occasional occurrence of hemorrhage ; and an 
illustration is related exactly in point, where the application of a ligature 
to a small polypus, in a patient w:ho did not consider herself pregnant, in 
consequence of a sanguineous effusion sometimes appearing, very speedily 
afterwards expelled an ovum. Of the cases by which this portion of the 
communication is illustrated, five have not previously been published ; and 
of these, with the diagnosis and practice, we shall now give a summaiy. 
In the/rtTof these, that talented and active practitioner, Dr F. H. Bams- 
botham, was consulted three weeks after delivery by Mr Moon : there were 
ineguW discharges of blood, the uterus was tender, as large as if sis 
mmiks preynaHt^ its aperture could only receive one finger, by which a 
body resembling a coagulum or a second foetus was felt. Ergot in large 
quantity was exhibited, whicb caused much pain daring the n^fat. Next 



I 



DR OLDHAM ON POLYPUS UTERI. 223 

day Mr Mood, being hurriedly called, feeling the os uteri opened and some- 
thing protruding, he passed his hand without much trouble into the uterus 
by the side of a tumour which was furnished with a stem that was im- 
planted into the fundus. This stem was firmly embi-aced ; and under strong 
uterine action, the hand, with a fibro-cellular tumour the size of an ostrich- 
®Rg» were expelled together ; and the patient recovered without an unfa- 
vourable symptom. The second case was communicated by Dr Radford^ of 
Manchester, who was consulted a fortnight after delivery. The patient, 
when he was called, was in articuh mortiSy and died two or three hours 
afterwards. She had frequent sanguineous discharges, violent paroxysms 
of uterine pains, and straining efforts, and the uterus felt larger than it ought 
to be. On dissection^ the uterus was found to contain a polypus about two 
inches in length, and varying from two inches to one and a half inch in 
circumference, growing from the fore part of the body. The third case Dr 
Radford saw the day after her delivery. She had hemorrhage, frequent 
small pulse, violent straining, and an enlarged state of the uterus. The 
hand was introduced into the uterus, a polypus the size of a pear noosed, 
the ligature daily tightened, and the excrescence detached on the eighth 
day. Dr Radford saw the fourth case six hours after delivery ; found her 
with a profuse dischaige, bearing-down pains, and unusual enlargement of 
the uterus. While preparing to apply a ligature, a severe uterine con* 
traction supervened, which detached and forced into the vagina a growth 
equalling iJie size of a moderately large orange. To case fifth Dr Radford 
was called soon after delivery. The symptoms already particularized in 
the other cases were here also complained of. On examination per vaginam 
a tumour the size of a foetal head of the seventh month was felt above the 08 
uteri. The placenta was still retained. The hand was introduced ; the 
tumour, which had but a small stem, separated by torsion, and, with the 
placenta, removed ; and the patient eventually recovered. 

It follows that the diagnosis in the foregoing important cases consists in 
an unusual enlargement of the uterus, occasional discharges of blood from 
the vagina, uterine pains, severe straining, and, on examination per vaginam, 
a foreign body being felt above the os uteri. By these cases it is also esta- 
blished that the presence of a polypus, whether growing in the interior or 
&om the OS or cervix of the organ, will not prevent impregnation ; that the 
hemorrhage, whether in the unimpregnated state or after parturition, arises, 
not from the uterine vessels, but from those of the excrescence ; and that, 
with safety to the patient, the growth may be removed by torsion or liga- 
ture, and sometimes by the contractions of the uterus alone. 



FORENSIC MEDICINE AND MEDICAL POLICE. 
Iodine a Preservative against Variola. 

Dk Schreibeb states, that he has found the administration of iodine useful 
in preventing the members of the fiunily of a person labouring under small- 
pox from being infected with the same disease. The formula he used was 
as follows : — 

R. Hydriod. potass. . . . gr. viij. 

Tinct. iod. . . . g*** xvi. 

Aque font. .... 5 U* 

S. A teaspoonful morning and evening. Dr S. invites practitioners to a 
further inyestigaiion of the powers of iodine in this respect. — Henk^s 
Zeitsdinft, No. IV^ 1843, 



224 MEDICAL MEMORANDA. 

Part IV.— MEDICAL MEMORANDA. 



How far is a Prisoner accused of Murder Jield guiltless provided the Deceated 
has a Surgical Operation performed upon him f 

" Should an operation be unnecessarily and unskilfully performed, the re- 
sponsibility of an aggressor would of course cease, if the death of a wounded 
party could be clearly ascribed to it. Thus, if in carelessly bleeding a 
wounded person, the brachial artery should be laid open, or if, in performing 
amputation, a large artery be imperfectly secured, so that the patient in 
either case die from hemorrhage, the prisoner is not responsible ; because 
it would be punishing him for an event depending on the unskilfulness of 
the medical practitioner. But supposing the bleeding or amputation to be 
performed with every proper care and skill, and yet, in the one case, 
phlebitis, and in the other tetanus, gangrene, or fever should destroy life, 
the prisoner will be differently situated. 

** The practice of the law is strictly consistent with justice. If the opera- 
tion be absolutely required for the treatment of a wound, — ^if it be performed 
with ordinary skill, and still' death ensue as a direct or indirect consequence, 
the prisoner will be held responsible for the result. It is presumed in these 
cases, that if the patient were left to himself he would, in all probability, 
die from the effects of the wound. If, therefore, a sui^geon, knowing that 
an operation would give a chance of saving life on such an occasion, did not 
perform it, it might be successfully contended in the defence, that the de- 
ceased had died, not from the ivound, but from the incompetency and neglect 
of his medical attendant. Hence it follows, that if, during this very neces- 
sary treatment, unforeseen though not unusual causes cut short life, no 
exculpation should be admissible, if it went to attack the best directed 
efforts made for the preservation of life. 

^* By an operation being absolutely required, we are to understand that it 
is necessary to preserve life. Bleeding and cupping may be necessary in the 
treatment of a wounded person ; but unless it could be sworn that this 
treatment was required for the preservation of life, it is doubtful whether, 
in the event of death occurring from these simple operations, the assailant 
would be held responsible for the fatal result. 

*' In 18279 two persons were tried in Edinbui^h for capitally assaulting 
another by throwing sulphuric acid over him. The death of the deceased 
was clearly due to phlebitis and conc<»nitant fever, following the operation 
of venesection, which was considered necessary in the treatment of the case. 
It did not appear that this bleeding was absolutely necessary for the preser- 
vation of life, but merely for the prevention of severe ophthalmia. The 
charge of murder was therefore abandoned : — ^this question of responsibility 
for the &tal result being considered to involve too nice a point to ensare 
conviction." — Taylor. 



ERRATUM IN LAST NUMBER. 
Page 131, end of third paragraph,/or aq. fontis, 3xii,, read aq. fontis, ^xii. 



I^intcd by Oliver & Boyd, Twooddate Court, High Sircet, Bdinbiirsb. 



THE 

NORTHERN 
JOURNAL OF MEDICINE. 



No. IV.— AUGUST 1844. 



Part I.— ORIGINAL ARTICLES. 



Observations on the Best Mode of Registering Deatlia, Read at 
an Evening Meeting of the Royal College of Physicians, June 
1843. By William Pulteney Alison, M.D., F.R.S.E., 
Professor of the Practice of Medicine in the tlniversity of 
Edinburgh, and one of the Physicians in Ordinary to her 
Majesty for Scotland. 

The subject of Registration of Deaths with a view to facilitating 
statistical inquiries into the history, causes, and prevention of 
diseases, has been pretty fully considered and reported on by a 
committee of this college ; and I think every one who has ex- 
perienced the difficulty of extracting satisfactory information from 
the Registers now existing, must admit its importance. A decided 
opinion was expressed by that committee, that the method adopted 
by the medical advisers of the Registrar-General in England, and 
according to which the deaths there occurring are arranged and 
classified, although a great improvement on the old bills of mortality , 
is liable to very serious objections. The objections which we 
stated have been considered at some length by Mr Farr, in a 
paper contained in the Fourth Annual Report of the Registrar- 
General of England ; and the members of this college may be 
somewhat disappointed at perceiving that, although expressing 
himself in complimentary terms towards us, he declines adopting 
any of our suggestions, and gives a decided opinion that his plan 
of registration is much superior to ours in almost every respect. 

As I am by no means convinced by his reasoning, I wish to 
lay before the college the reasons which still lead me to think 
that the plan which we proposed is decidedly preferable, and 
that if a registration bill for Scotland shall be brought forward, 
we ought to endeavour to have the registration of deaths under 
it conducted according to our plan rather than according to that 
which is now adoptea in England. 

We must bear in mind that, in a scientific view of the subject, 
the main objects of such registrations are — 

2 F 



226 



ON REGISTERING DEATHS. 



1^^, To secure the greatest amount of authentic information as 
to the causes of death. 

2dlVf To separate distinctly that information which must ne- 
cessarily be only general, from that which may be expected to be 
minute and precise ; and, 

Sdly, To facilitate the labours of future statistical inquirers 
who may wish to have various portions of this informatioQ 
thrown into the form of tables. 

The objections which we stated to the English plan related, 
1st, to the form of the schedule according to which the deaths 
are registered ; 2dly, to the nomenclature of diseases, to which 
all practitioners are requested to conform. 

1. The essential difference between our schedule and theirs is, 
that we wish to have that part of the Register appropriated to 
the cause of deaths, divided into two columns — one to be filled 
up in every case without exception, but which is to contain, not 
the name of the disease (unless in the case of well-known epi- 
demics) but only the seat of the disease, and its nature as acute 
or chronic ; the other column to give the name of the disease, 
always on medical authority, and only when well ascertained. 
This column will be filled, of course, in a much smaller number 
of cases, but will always give precise and accurate information, 
in conformity to printed directions to be put into the hands of all 
practitioners. We suggested, also, that each column should be 
subdivided into two, — -the first stating what diseases are acute and 
what chronic ; the second stating what disease caused death, and 
what (if any) previously existed. 

On the other hand, in the English registers only one column 
is assigned for the cause of death ; and Mr Farr thinks it pre- 
ferable to have all the particulars stated in this single column. 
The following sketch shows the difference of the two plans : — 



Plan recommended by the Edinburgh 
Committee, 


; Improved English Plan. 


Dumtion and Seat of *, ^^. 

Disease. Name of Disease. 


Cause of Death. 


Acute, 
Bowels. 


Chronic. 


Causing 
Death. 


Previously eHst- 

ing Disease, or 

cause. 


— 


Dysentery. 


— 


Dysentery, 20 days. 


— 


Chest. 


Consump. 
tion. 


— 


Consumption, 1 year. 


Chest 


— 


Pleurisy. 


Epidem. fever. 


Typhus, 17 days. 
Pleurisy, 2 days (p. mort.) 



Our reasons for preferring the plurality of columns are these : 
1*^, We consider it quite certain that, as to a large proportion 



ON REGISTERING DEATHS. 227 

of the deaths, there will be no report by a medical man, on 
which reliance can be placed ; the cases either having been 
seen by none, or seen so cursorily, or at so advanced a period, 
as to make it impossible for them to pronounce confidently on 
their exact nature. This, I think, all practitioners will admit to 
be true, even of many cases of which they could say, with a good 
deal of confidence, whether any and what remedies were l^ely 
to be of service ; and if so, it is obvious that to require or 
even to invite a declaration of the cause of death, in the same 
mode, in all cases whatever, is to make the statistical statements 
to be founded on those registers an almost certain source of 
fallacy, and of erroneous doctrine. 

- This is substantially admitted by Mr Farr himself, for he 
says that in England the names of diseases have often been 
returned, particularly as to cases not seen by medical men, in a 
very unscUisfactory manner ; but the remedy which he suggests 
is, to have all such cases inquired into after death by medical 
men, and then named ; which, as it appears to me, is not a 
procedure that can be adopted, at least in Scotland, with any 
prospect of more satisfactory results. 

But, on the other hand, it is equally certain that there are 
various particulars which are easily ascertained, in regard to all 
cases without exception, and which of themselves, if ascertained 
uniformly and universally, will give results of great importance. 
These are, not only the age, sex, precise locaUty, and condition or 
mode of life of the deceased, but likewise the auration of his dis- 
ease, as acute or chronic ; in the case of well-known epidemics, the 
name may be safely assigned, and in all cases of sporadic diseases, 
the part of the body in which the chief symptoms appeared. 

The importance of having these particulars recorded as to 
all cases, combined with the impossibility of having a scientific 
statement of the cause of death in many, forms the difficulty 
which we propose to surmount by the two distinct and even 
subdivided columns. 

It is no doubt possible to record all the particulars that we 
wish in a single column, and to have the names of diseases only 
assigned in that column when it can be done accurately, and 
afterwards to pick out, from the entries there, the cases which 
are accurately named, as distinguished from those of which we 
know only the seat and duration. But let us observe the in- 
conveniences of this mode of proceeding. 

1st, There is much greater trouble m throwing the informa- 
tion required into the form of tables. For example, if we 
wish to know how many acute and how many chronic diseases 
of the head are recorded in a given register and within a given 
time, how many of these have been registered in general terms 
only, and how many accurately named, we should have the trouble 
of seeking out and reflecting on the import of a great number of in- 
dividual words, instead of merely summing up a column of figures. 



228 ON REGISTERING DEATHS. 

2dly, By having only one column, in which all the particn* 
lars regarding the cause of death are to be stated, the attention 
of those making up the registers, whether medical men or not, 
is not fixed on the different particulars in regard to fatal disease 
which demand separate consideration, and there is a much 
greater chance of careless and fallacious registration. 

ScUy, No distinct line of demarcation is drawn between 
cases carefully observed and recorded by medical men, and 
cases the real nature of which may be quite unknown. 

I admit that there is some force in the objection stated by 
Mr Farr to our division of acute and chronic diseases, accord- 
ing as they are of less or more than six weeks' duration ; viz. 
that you might as well divide all people into yoimg and old, 
according as they are a,bove or below the age of twenty. But 
still it appears to me, that the chief practiced use which can be 
made of the entries of the duration of diseases, in Mr Farr's 
own column, will be to make up tables of diseases of different 
parts of the body and in different times and places, as acute 
or chronic, and I do not know a better line of distinction 
between acute and chronic diseases than that which we have 
stated. The formation of such tables will of course be ex- 
tremely facihtated by having these separate columns ; and 
then, as the precise duration may be stated in each individual 
case in one or other of those columns, the more precise informa- 
tion which he considers essential may be obtained from our 
register equally as from his. 

But the objections which he states to our having a column for 
the seat of disease, as distinguished from the name, proceed on 
an entire misapprehension. He says that nobody who is to use 
the registers will require to be informed that c(msumption is a 
disease of the lungs, and so forth ; — not observing that our rea- 
son for wishing the latter fact to be stated in all cases is, that we 
are sure it can be accurately stated in many, in which the dis- 
ease, cannot be named, or will be named incorrectly ; therefore, 
that by this column we gain a piece of authentic and important 
information, extending to a much larger number of cases than 
the named diseases. But we have the names given as distinctly 
as he has, in all those cases in which that information can be given 
on proper authority, and is therefore of real value. 

That he has misapprehended the practical working of our plan 
appears distinctly from his criticism on it, at p. 215 (of Fourth 
Annual Report) : " The Edinburgh Committee have assumed 
that distinct diseases, which cannot be distinguished in all cases 
and by all practitioners, should invariably be confounded under 
the same entry in 'the register. For instance, because it is pro- 
bable that C and D would often confound croup, quinsy, and 
laryngitis, they would direct A and B and all well-informed 
practitioners to return the three diseases to the registers as ' acute 
disease of the windpipe.' What would be the consequence of a 



ON REGISTERING DEATHS. 229 

reeommendatioii of ibis kind ? If the cases of croup, laryngitis, 
and quinsy are stated separately, it will be an easy matter to 
add ^em together ; but if the three diseases be confounded sys- 
tematically m all the registers, they can neyer afterwards be 
analyzed. According to Dr Alison's plan, all the physicians and 
surgeons of the country, whatever might be their sluU in diag- 
nosis, whatever be the progress of medical science, would be 
bound to assign the cause of death in general terms, instead of 
the precise terms by which diseases are generally designated." 

Now, according to our plan, every physician and surgeon will 
be at hberty to exercise his skill in diagnosis to the utmost, be- 
cause he will be (zsked to give a name to every case which he 
has seen (although a shorter and simpler nosology than that of 
Mr Farr will be recommended to him) ; but it Can be no great 
trouble to him, besides giving the name, or when he is uncertain as 
to the precise name, to enter the disease in our first column as one 
of the head, chest, or abdomen ; and by doing so he will enable any 
future inquirer easily to enter the case in two distinct lists, both 
equally authentic, the one containing certain particulars only, the 
other, a shorter list, containing more minute information. 

It is to be observed, that in all Mr Farr's lists there are a 
number of cases recorded merely as disease of the head, disease 
of the lungs, Sfc, which is an admission of our principle, that the 
seats of diseases can be stated in a number of cases where the 
names cannot be assigned. But these cases, from the deficiency 
of his plan, are not stated as acute or chronic ; and their number 
is so small in comparison to those where the disease is named, as 
to show very distinctly, that on the names assigned to many of 
these cases little reliance can be placed as a scientific record. 

I think I have shown that the plan of two columns with sub- 
divisions, — although a little more troublesome to the framers of 
the schedules, — ^will be in fact less troublesome to the recorders 
of deaths, than Mr Farr*s plan of crowding so many particulars 
into single columns, while it will give great facilities to future 
sdentific inquirers. 

There is a suggestion contained in Mr Chadwick's Report 
upon the sanitary condition of the labouring classes, which shows 
very distinctly the importance of having authentic records, not 
only of the diseases causing deaths, but of the circumstances 
attending and causing diseases, viz., that in addition or as supe- 
rior to the medical officers in charge of districts (that is, of unions 
under the amended Enghsh poor-law) there should be a small 
number of superintendent medical officers charged with all 
inquiries affecting the public health, and that one of their duties 
should be the examination of the registers, to ascertain whether 
any particular diseases prevail at particular times in individual 
districts or classes of the community in an unusual degree, and 
if so, whether these can be traced to removable causes. It is 
obvious how much the labours of such men would be facilitated 



230 * ON REGISTERING DEATHS. 

by such a form of the registration of deaths as we recommend, 
with one simple addition, that our last column should comprise, 
as suggested above, not only any previously existing disease, but 
cause of disease.* 

Of the faciUty of registers being kept in the way we propose, we 
have fortunately an example in the parish of South Leith, where, 
under the direction of Mr Lyon, the session-clerk, the register 
has been kept for some time past almost precisely on that plan. 

II. On the hst of diseases adopted in the English returns, as 
compared with the much shorter list recommended by the com- 
mittee of this college, I do not think it necessary to enlarge, be- 
ing quite content to leave it to the judgment of the profession, 
whether it be expedient, or likely to lead to useful results, to 
invite all practitioners to enter on the minute and sometimes am- 
biguous distinctions in giving the names of diseases which the 
English lists require. But there is an unfortunate difference of 
opinion between Mr Farr and our committee in regard to the great 
leading division (of the importance of which we are all agreed), — 
that 01 plagues, or epidemic and endemic diseases, occurring only 
within certain limits of time and space, and the sporadic diseases, of 
more uniform occurrence, — which demands a little consideration. 

Mr Farr*s principle is, that if any disease, or if cases which 
assume the characters of any disease, and are not easily distin- 
guished from it, become epidemic at greater or less intervals of 
time, — even although it be only in what he calls unhealthy places 
and among the sickly classes, — ^that disease must be ranked 
among the plagues, and all cases of it, in all seasons, and how- 
ever isolated they may appear, must be set down in the great 
division of epidemic and endemic diseases. Any other plan, he 
says, would lead to endless confusion. 

Hence he sets down every year all cases of croup, of aphthsB, of 
dysentery, cholera and diarrhoea, and erysipelas, among the epi- 
demic, endemic, and contagious diseases. He is strongly impressed 
indeed with the importlince of distinguishing croup, which he thinks 
an epidemic disease, from laryngitis and from quinsy, which he 
ranks among the sporadic (wmch distinction I apprehend to be a 
difficult matter) ; but thinks that all the cases of cholera now oe- 
currin^ must be classed with mali^ant or Asiatic cholera, and that 
it is quite as unreasonable to distinguish them, as to separate mild 
from malignant scarlatina; whereas I believe that we in Edinburgh 
will generally maintain, not only that in a great majority of cases 
even fatal sporadic cholera is easily distinguished from the ma- 
lignant, but that they are essentially and pathologically dis- 
tinct diseases, and that the true malignant cholera was never seen 
in Scotland before 1831, and has not been seen since 1833. 

In regard to several of the diseases in question — dysentery, 
erysipelas, croup, or even diarrhoea — ^we must allow that occasions 
do occur when they prevail epidemically or endemicaUy, although 

* Chadwick*s Sanitary Report, p. d52. 



ON REGISTERING DEATHS. . 231 

not to be distinguished by their symptoms from the sporadic 
and often isolated cases, which may often be distinctly traced to 
cold» to repletion, or other causes of continual occurrence. But 
I cannot think it right, — on the contrary, I think it must tend 
to endless confusion, — ^to rank, on that account, all cases of these 
diseases among plagues or epidemics. 

The reason of making a distinct class of epidemics, and lay- 
ing stress on their distinction from other diseases in statistical 
inquiries, is, that the study of their history, causes, and means 
of prevention, is essentially distinct from the study of the same 
particulars in regard to the sporadic diseases ; but this reason 
exists no longer, when we find that all cases, however isolated, 
of croup, aphthsa, diarrhoea, or cholera, are ranked among the 
epidemics, with smallpox and measles. Nobody can suppose that 
the means of prevention, applicable to ordinary cases of any of these 
diseases,haveany analogy to the means by which we strive to arrest 
the extension of malignant cholera, or of plague, and with a view 
to which we study the histories of the diffusion of these diseases. 

The only way, as it seems to me, of avoiding such difficulties, 
or even absurdities, is that which we formerly suggested. Let 
each of those diseases, when it occurs, as usual, in isolated cases, 
be entered among the sporadic diseases ; but when any prac- 
titioner meets with such cases occurring so frequently, within 
narrow limits of time or space, as to indicate, m his opinion, 
the existence of a local and temporary cause, let him be re- 
quested to prefix the term epidemic, and those cases may then be 
ranked in the tables along with the epidemic diseases. And 
although there may occasionally be a difference of opinion as io 
whether the term epidemic is rightly applied, yet as in every such 
case the number of deaths attributed to such epidemic influence 
in any locaUty will appear, it will always be in the power of 
any one who uses the register to form a judgment on the point, 
whether the term is truly applicable. 

I have the less difficulty in recommending this, as it is exactly 
what is done (and the principle of doing it therefore tacitly admit- 
ted) in the Eriglish tables as to two remarkable diseases. Mr Farr 
has bronchitis among the sporadic diseases, and influenza among 
the epidemics, I think quite correctly. But influenza may be 
very reasonably called an epidemic bronchitis, and certainly 
it is at least as difficult to distinguish it from many sporadic 
cases of catarrhus senilis, as to mstinguish malignant cholera 
from the common cholera of this country, proceeding from an 
increased flow of bile. 

Again, Mr Farr has among sporadic diseases what he calls gas- 
tro-enteritis, and explains as being inflammation of the mucous 
membrane of the bowels ; but we all know that this inflamma- 
tion occurs frequently and epidemically in connexion with 
typhoid fever; and that it is still disputed, whether there is 
not an epidemic typhoid fever, distinct from the true typhus. 



232 ON REGISTERING DEATHS. 

and attended uniformly with this kind of inflammation. Such 
complex cases, if they have any distinctive name in the English 
tables, must, I presume, be called epidemic gafltro-enteritis, as 
distinguished from the sporadic cases of that inflanunation. This is 
another example where he must rank some cases of a disease as 
sporadic, and others, occurring in certain times and places, as 
epidemic. We have only to extend the practice, which I think 
he must adopt in regard to these two diseases (if he is to embody 
in his tables the information which they certamly ought to give 
in regard to them) to other cases, in order to have a complete 
justification of the mode of proceeding recommended by us. 

For these reasons, I must be permitted to express the hope, 
that if we shall have the satisfaction of seeing a registration 
act introduced into Scotland, any influence which this college 
may possess will be exerted to secure, that the parts of the 
registers appropriated to the causes of death may be kept in the 
way that our committee has recommended, in preference to that 
which has been adopted in England. 

Note. — Form of Queries by whkh the Register isfiUed up in South Leith. 
No. 

Name of deceased ... ... ... 

(StaU the Maidm at wU at Married Nam qf ~ 

Femafet.) 

Sex 

Condition, as Single or Married, or 
Widowed 



Age, last birth.daj ... ..._ 

Relationship to, if not Head of Family, 
and Employment, if any ... ..._ 



Head of Family and his Employment _ 

Exact place of ordinary residence .. _ 

{Slate the Street, No, qf ditto or kmd,) 
Date of Death, and place of it, if not 
the same as ordinary Residence 

Date of Burial 

Place of Interment 

Medical A ttendant, 

Or if none, the Disease, if distinctly 

known, seat of it, and duration 

(Signed) Undertaker. 

Nois.— R it rejwtted (kat the Medieed Attendant ituerttkeSdeia^ntmenftkeJHeeate. 
Seat of Disease 

Duration of do. 

Disease causing Death 

Disease previously existing, if any . . . ._ 



(Signed) __Med. Atf» 



ENLARGEMENT OF THE HEART. 233 



On the Diagnosis and Treatment of Enlargement of the Heart, 
connected with Incompetency of the Aortic Valves. By 
William Henderson, M. D., Professor of Medicine and 
General Pathology in the University of Edinburgh. 

In the first number of this journal I published a short 
])aper on the employment and action of digitalis in certain 
diseases of the heart, and noticed incidentally the speculative 
grounds on which it appeared to me that the characteristic 
effect of digitalis on the frequency of the heart's action, though 
eminently serviceable in some diseases of the heart, was calculated 
to be injurious in a certain affection of the organ ; and I signified 
my intention of adverting on a future occasion to other expe- 
dients, common in the ordinary treatment of organic diseases of 
the heart, which are improper in that of the particular disorder 
to which I allude. In reference to this disease, it was stated, — 
" Patency of the aortic opening, at that period when the 
ventricles are being filled, necessarily admits of regurgitation 
from the aorta, the effects of which are an overloading of the 
left ventricle, and gradually an enlargement of it — an enlarge- 
ment so great ultimately, if the patient survive long, as to ex- 
ceed, often to a great extent, that which occurs under any other 
circumstances. • * * Such being the tendency and issue 
of that overloaded condition of the organ which results from re- 
gurgitation from the aorta, it will be granted that whatever 
increases the amount of the regurgitation must accelerate the 
progress of the enlargement. That the less frequently the 
heart beats, the greater will be the opportunity for this re- 
gurgitation, is sufficiently obvious ; and hence it is, that the pro- 
longed action of digitalis cannot but be injurious when the aortic 
valves are not competent for their office." If it be not in 
consequence of the regurgitation that the ventricle becomes 
enlarged, of course it cannot be by rendering the regurgitation 
more considerable that digitalis can contribute to the progress 
of the enlargement ; but if the regurgitation do operate in the 
manner supposed, it will not be difficult to admit, that the 
greater the amount of it, the more rapid will be the increase of 
the enlargement — ^that, in short, the effect will bear a proportion 
to the cause. I apprehend that no doubt can be entertained of 
the manner in wliich the enlargement is effected, — that it is 
actually due to the reflux of blood from the aorta, as a con- 
tinued and habitual cause of over-distention of the ventricle ; and 
I do not conceive it necessary to adduce any facts or arguments 
in support of the statement. At the same time, it is not main- 
tained that the regurgitation acts, in producing the enlargement, 
merely in the way of mechanically distending the left ventricle ; 
on the contrary, it is doubtless true that the increased exertion 

2g 



234 ENLARGEMENT OF THE HEART. 

on the part of the organ at every pulsation, rendered necessary 
by the greater amount of blood it has to expel and sustain, 
and the greater frequency with which it almost always pulsates 
in this disease, contribute to induce that increased nutrition 
which is characteristic of muscular tissue, the contractions of 
which are for a length of time more powerful and more frequent 
than usual. 

Assuming, then, that the regurgitation is the cause of the 
enlargement of the heart, it becomes a matter of much practical 
importance to reflect on the consequences which may result from 
the use of means by which the regurgitation may be increased. 
I adverted in ray former paper to the experience of Dr Corrigan 
in reference to digitalis, and remarked that my observation con- 
curred with his as to the less satisfactory operation of that medi- 
cine in general, in cases of incompetency of the aortic valves, 
compared with its effects in most of the other diseases of the 
heart. The allusion which I made to the manner in which the 
digitalis may be understood to act so differently in the disease 
in question from what it does in the others, is quite in accordance 
wiUi Dr Corrigan's explanation of the circumstance as expressed 
in the following quotation : — " If the action of the heart be ren- 
dered very slow, the pause after each contraction will be long, 
and consequently the regurgitation of blood must be consider- 
able. Frequent action oi the heart, on the contrary, makes the 
pause after each contraction short ; and in proportion as the 
pauses are shortened the regurgitation must be lessened."* 
Again, " To retard in such circumstances the action of the 
heart would be to do an injury. In every case of this disease, 
in which digitalis has been administered, it has invariably aggra- 
vated the patient*s sufferings. The oppression has become 
greater, the action of the heart more laboured ; the pulse 
intermittent, and very often dicrotic, from the heart being 
imable by a single contraction to empty itself; general conges- 
tion and dropsy, if present, have been mcreased, and in some of 
the instances bronchitis from congestion has been induced ; the 
respiration more laborious, and the strength so much sunk, that 
patients seemed almost moribund. From this state they only 
recovered by omitting the digitalis, and putting them on stimu- 

lants."t 

These observations of Dr Corrigan have been for twelve years 
accessible to the profession, yet I do not remember to have heard 
them once acknowledged as' just, while I have often witnessed 
the adoption of the practice which he condemns. Since I per- 
used his paper seveml yeai-s ago, and had learnt how to distin- 
guish the disease of which it trcjits, I have not had recourse to 
the protracted employment of digitahs in the treatment of it ; 

* £ilinborgh Mediral and Surgical Jourua), voL xxxvii. p. 242. t Ibid. 



ENLAUGBMENT OF THE HEART. 235 

but from what I haye noticed of its lengthened employment by 
others, I have no doubt of the accuracy of his doctrme as a gen- 
eral fact. I cannot say, however, that my experience goes to 
the extent stated by him in the following sentence : — " In no 
case of this disease did digitalis produce the slightest good effect ; 
and in all, the patients, while under its exhibition, were always 
worse." On the contrary, I have not unfrequently remarked 
considerable relief to result from its employment in cases in which 
the disease appeared to have been of no very long standing, op 
to have entailed comparatively little dilatation of the left ven- 
tricle, and to have produced but an inconsiderable impression 
on the general health. In several persons affected with the dis- 
ease, yet still robust or plethoric, digitalis, aided by a moderate 
blood-letting even, I have known to produce verjr striking reUef 
to oppression at the chest and difficulty in breathing ; and I can 
account for the strong terms in which L)r Corrigan expresses the 
very different results of his experience, only by supposing that his 
cases were all in an advanced stage when the digitalis was ad- 
ministered. Yet I must add, that even in an advanced stage of 
the disease I have not found that " the patients while under its 
exhibition were always worse ;" for it has pretty often happened 
that the medicine, though continued for a considerable time, had 
no effect on the frequency of the pulsations of the heart, and 
was unattended by any change in the symptoms. 

What I particularly desire to solicit attention to, is the general 
impropriety of the ordinary practice in diseases of the heart, — 
repeated evacuations of blood, frequent and prolonged employ- 
ment of digitalis, and scanty nourishment — ^in incompetency of 
the aortic valves ; and as an example of the evils which result 
from it, I extract the following paragraph from Dr Corrigan 's 
paper : — " One case may be mentioned, out of many that oc- 
curred, showing the bad effects of debilitating treatment on the 
disease before us, and exemplifying the evil of acting as if one 

Erinciple were sufficient for guiding us in the treatment of all 
eart diseases. The treatment ordered was in accordance with 
that generally recommended, consisting of repeated small bleed- 
ings, blistering, the exhibition of digitalis, and the most rigid 
regulation of diet, a total abstinence from animal food, and even 
a spare allowance of vegetables and milk. At the time the 
patient, a young man, was put under this treatment, he was not 
in an alarming state ; but the disease being recognised as heart 
disease, he had the fortitude to submit to a course which he was 
led to expect held out a prospect of cure. Bleeding after 
bleeding and blister after blister were repeated, starvation en- 
forced, and digitalis exhibited, until the patient was reduced to 
such weakness, that he had scarcely strength to raise himself in 
bed. The local disease was all this time, however, growing 
worse ; for the palpitation, cough, &c., were, from the slightest 



236 ENLARGEMENT OF THE HEART. 

cause, increased to a greater violence than previously to the com- 
mencement of the treatment. The plan was, nevertheless, per- 
severed in, until the patient's death being supposed at hand, 
this debilitating treatment was discontinued. From that hour 
the patient got better ; and as his muscular strength returned, 
the embarrassment of breathing, palpitation, cough, &c., became 
less and less urgent. The patient is still alive, the disease is 
still present ; but with full living and good air he is able not 
only to take considerable exercise, but even to undergo the 
fatigue of a business that constantly requires very laborious 
exertion." (P. 241). I can adduce no example so fully illustrative 
of the truth and importance of the practical views promulgated 
by Dr Corrigan. I have, however, witnessed some cases in 
which the depleting and reducing plan had aggravated the suf- 
ferings, and others in which good diet and exertion, not carried 
to an extreme, had been felt the best adapted to the comfort and 
ease of the patients. One instance I remember of a porter, 
affected for a long time with this disorder, who continued for 
years fit for liis laborious occupation, indulging repeatedly duriug . 
the day in potations of malt liquor ; and whether we credit bis 
account or not, that he felt them necessary to the freedom of 
his breathing, &c., I was satisfied that, under the exciting in- 
fluence of them, he exhibited no evidence of that suflFering which 
could not fail to have been produced in any other kind of 
diseased heart, equally considerable, by the same habits. 

In alluding to the diagnosis of this condition of the aortic 
valves in my former paper, I observed that it was perhaps 
easier than that of any other disease of the heart. But on this 
subject I have not leisure to enter at present, nor is it of conse- 
quence that I should, seeing that in Dr Corrigan's paper al- 
ready referred to, in Dr Hope's work on diseases of the heart, 
and in a short essay of mine, published a few years back in the 
Edinburgh Medical and Surgical Journal, ahnost all that I 
could have to notice is fully detailed. The point which is 
chiefly dwelt on in the last of these accounts of the disease, is 
the lengtliened interval which occurs between the impulse in 
the region of the heart during the contraction of the ventricles 
and the beat of a distant artery, such as the radial ; and I 
would only mention here, in addition to what I have stated in 
that paper of the value of this sign, that it is sometimes present 
when none of the other signs commonly considered indicative of 
the disease are, — ^in particular when there is no regurgitant 
murmur. 



CONTRIBUTIONS TO INFANTILE PATHOLOGY. 237 

Contnbiitions to Infantile Pathology, By Alexander D. 
Campbell, M.B. Oxon, F.R.C. S.E., and Physician-Ac- 
coucheur to the Royal Dispensary. 

Tu)o Cases of Icterus Gravis Infantum from D^iciency of the Hepatic and 
Cystic DuctSy and one from firm Plugging of the Common Duet. 

Although some of the following cases belong to that class in 
which our professional knowledge can be of but little avail, they 
are not without interest or means of improvement to the scienti- 
fic practitioner. Mrs R. , the mother of three children (two 

of which are alive and healthy), was delivered on the 20th of 
February of her third child, a female, having had no children 
for four years previously. During this last gestation, shfe 
suffered severely from pain in the right side ; but except that, 
she had no other complaint than is usual in pregnancy. Her 
last labour was tedious, on account of the child being rather 
large and well developed. The dajr after the child was born, 
its whole body became exceedingly jaundiced ; but as she took 
the breast regularly, and evinced no further evidence of indispo- 
sition, the icterus did not attract any particular attention ; the 
funis separated naturally on the fifth day ; the stools were con- 
stantly Ught-coloured ; and the urine possessed a brownish 
tinge. On the ninth morning after birth, in consequence as 
was supposed of too much milk rushing to the pharynx, and a 
little perhaps entering the larynx, a fit of coughing supervened, 
which was followed by a discharge of blood from the umbilicus ; 
and before the child was seen, it was supposed that the quantity 
lost amounted to about two ounces. Caustic and compresses 
were used, which suspended the effusion ; there was also slight 
vomiting. The next morning I received a message that the 
hemorrhage had returned; a graduated compress was now 
applied, which again checked the effusion ; on this occasion the 
loss had not been so copious. In the afternoon of the same day 
the compress was removed, when there was no appearance of 
there having been any new discharge ; for the sake of caution, 
some of the pulv. alum comp. was applied to the umbilicus, and 
the compress replaced; the child, however, died in about au 
hour afterwards. The infant took the breast well to the last, 
appeared to suffer no pain, and expired without apparent con- 
vulsions or coma. Tho remedial measures employed were the 
administration of occasional doses of ol. ricini, hydrarg. c. cretfi, 
and calomel, all of which operated easily on the bowels, but pro- 
duced no change in the colour of the stools. The blood which 
escaped from the umbilicus contained a large quantity of bile, 
as was evident from the deep tinge of biliary matter communi- 
cated to the clothes which received it. 

Post-mortem examination forty-four hours after death. — The 
skin was universally of a bright yellow or lemon colour {color 



238 CONTRIBUTIONS TO INFANTILE PATHOLOGY. 

aurantiacus), the body generally was well developed, and o ^ ■ <5i 
the abdominal and thoracic muscles, adipose tissue was deposi^tz- ^ci 

in large quantity. The cavities of the pleura, pericardium, 2m :mh.c1 

peritoneum, contained a small quantity of serum slightly t in( j * ^3cl 
with bile; the internal organs, the liver and spleen except^^^<l, 
Avere of a pale yellow, and were all perfectly bloodless, x ~ Ibxe 
thoracic and abdominal viscera were then removed en mass^ in 
order to allow a more minute inspection. The liver natura— Zlljy 
first attracted attention ; it was of its normal size, and when ^ezi^^mjLt 
into, it appeared somewhat softer than usual, full of bile, and^ oi 
the colour of burnt umber. The gall-bladder was very siE:a»_.^a-H 
and collapsed, contained only a little mucus, in colour and cczz> za:^- 
sistence resembUng gelatine, and formed a close sac hamng -^i-^ 
outlet y the excretory ducts leading from the gall-bladder and Iv^^^^^i 
being absent. 

Through the kindness of Mr Miller, surgeon of this city ». 3 

have been favoured with the following case of a somewBnB. ^mJL 
similar nature. " J. T. presented at birth all the appearaa^zi^^^s 
of a mature healthy child ; on the following day the skin w^^ ^MJi 
observed to be somewhat yellow, but not more so than in ca*^^ <:>« 
of icterus occurring soon after birth. Instead of disappearis:rm. ^"t 
however, as generally happens in that mild complamt, -Aii^lie 
jaundiced tinge became more deep and permanent. WithL^d^^ a 
few days after birth, the abdomen was observed to bo ratBin*-^'' 
tumid, in consequence of enlargement of the liver. The cti»-ild 
sucked well, but was often attacked with diarrhoea and voik=:»-5*^ 
ing ; the faeces were constantly pale and ash-coloured, and -^fcv^e 
urine of the usual saffron hue observed in jaundice. The s^--^^^-"^ 
was latterly tinged of a greenish brown. With the except ^:^^^^^ 
of the liver, which increased enormously, so as at least to oocv- HP^ 
bodithe hypochondriac, the whole epigastric, and the greater p^^^'^^ 
of the hypogastric regions, and even to dip into the right HL::^^ ^^ 
fossa, the other organs seemed to remain stationary. 1 "^ -^® 
features gradually assumed a peculiarly shrivelled appearan ^ ^"^ ^^ 
which, with their morbid colour, rendered the child a disgusti.^ -^^^S 
object. After surviving six months, it was carried off by ^^^ 
attack resembling one of cholera, having for some hours h^ic::^^^^ 
its death incessant vomiting of large quantities of a matter simi^t-^*'' 
to coffee grounds. On a ^^iv^ixA 'post-mortem examination, neiHSm'^^^ 
a gall-bladder nor bile ducts could be discoi'ered; the liver ^r^-^"^ 
verjr much enlarged; the vena portae, hepatic artery, and ^^7 
patic veins were all perfectly normal ; the yellow hue pervai^^^ 
the internal organs generally, but was more particularly remart^^ 
on the inner coat of the blood-vessels.'* 

The following case, in some measure analogous to the tw<> 
preceding, I owe to the kindness of Dr Maxwell Adams of ihi^ 
city: — ''November 1, 1843. — Mrs C. was dehvered, after a 
natural labour, of a healthy male cliild ; she had previously had 



CONTRIBUTIONS TO INFANl ILE PATHOLOGY. 239 

three children, two girls and one boy ; the girls are still alive, 
but the boy died on the eleventh day after birth, under circum- 
stances wmch will be presently adverted to. On the third day 
after birth, the skin of the new-born infant assumed the usual 
yellowish tint of icterus rnitis. There was no apparent derange- 
ment of any function ; yet the parents of the child, especially the 
fether.. expressed great uneasiness for his safety, from the cir- 
cumstance of their former male child having become yellow about 
the same time after birth. They stated that the yellowness 
had increased ; that hemorrhage had occurred from the umbi- 
licus on the seventh day, two days after the funis had been de- 
tached; that it had continued with lin increase in the yellow 
colour of the skin until the eleventh day, when the child died 
without experiencing any apparent pain, fit, or struggle, and 
only a few hours after partaking of the breast. The case ap- 
peared rather a singular one ; but as not much credit is to be 
attached to the accuracy of reports of disease by non-medical 
reporters, but little attention w^s paid to the recital. To the 
child then under treatment castor-oil was ordered to be exhibited ; 
and it was attempted to be impressed on the miiids of the parents 
that the case was not of such a nature as to cause any unusual 
alarm. 

" Nov. 4. The castor-oil had operated freely ; the meconium 
had disappeared from the stools ; tlie yellow tinge had become 
brighter and more vivid, involving the nails and conjunctivAB ; 
in other respects the child appeared to do well. Small doses of 
hydrarg. c. creta were ordered, together with the tepid bath, 
and gentle friction over the region of the liver and stomach. 

" Nov. 7. I received a hurried call this morning, the nurse 
having observed, on removing the roller, that there was an oozing 
of blood from the navel. An astringent lotion and graduated 
compress were applied, which had the effect of arresting the 
hemorrhage during that day and the succeeding night. The 
other remedies were continued at more distant intervals. 
Yesterday the cord separated, leaving a clean and healthy 
surface. 

** Nov. 8. The hemorrhage had returned this morning. The 
compress, which was soaked with blood, was removed, and a 
cork, made convex at the extremity, and covered with chamois 
leather, was substituted. The tinctures of the muriate of iron, 
and catechu, alum, and various other styptics, were severally ap- 
plied, witli the effect of at least restraining the oozing, which 
was not by any means formidable. The child was not teverish, 
nor did he appear to suffer pain or uneasiness. 

" Nov. 10. The blood continued to ooze away from below the 
compress. The use of every means that suggested themselves 
to the other medical gentlemen who visited the child was per- 
severed in. The loss of blood was inconsiderable, nor was 



240 CONTRIBUTIONS TO INFANTILE PATHOLOGY. 

there any symptom of fever, spasm, or debility, present ; on the 
contrary, the child appeared comfortable and thriving. The 
alteratives and gentle aperients were continued with the local 
means. 

" Nov. 11. I was hurriedly called this morning, and on my 
arrival found the child dead. No alteration had taken place in 
the symptoms until a few hours before death, when he refused 
the breast, and gradually sunk into a comatose state, and almost 
imperceptibly expired. I do not think that more than one 
ounce and a half of blood was lost during the whole time the 
hemorrhage continued. 

" Autopsy, — The body oh being stripped was of a bright yellow 
colour, plump, firm, and well developed ; and incision was made 
from the top of the sternum to the pubes to the left side of the 
umbilicus, leaving it, with the vessels entering the liver, entire 
for more minute inspection. Adipose tissue was deposited in 
large quantity below the integuments. The intestines, fatty 
parts, and in fact the whole intOTnal organs, except the liver and 
spleen, exhibited the same golden yellow tinge as the outer skin. 
'J'he liver appeared slightly congested and more dense than 
usual, but there was no sloughing of any of the vessels that had 
entered it from the funis, nor was there any trace of disease 
about the navel to indicate the source of the hemorrhage. The 
mucous membrane of the stomach seemed a little softened, and 
there were three or four small spots of ulceration observed upon 
its surface, which were attributed to the irritating action of the 
medicine administered. The gall-bladder contained a quantity 
of bile which could not escape, owing to an indurated cord-like 
plug of inspissated bile, which occupied the duct leading to the 
duodenum. The umbilical vein contained a clot about an inch 
in length. The head was not examined." 

Of the preceding cases, the first and third are of the most 
interest, and more especially the latter, as in it there was a pos- 
sibility of cure, but the former was beyond the power of any- 
remedial measures. There are also many points of similarity 
between them. In both, the jaundiced tinge showed itself the 
day after birth ;. in both, the hemorrhage occurred two days 
after separation of the cord, in the one on the seventh, in the 
other on the ninth day after birth ; in neither did the children 
appear to suffer the slightest uneasiness, but slept well and took 
the breast well, until within a very short period before decease ; 
in the latter case, its interest was increased by the circumstance, 
that the parents had previously had a child affected in the same 
way, and which died from the same disease ; and in both, the 
children were very stout and healthy, and much adipose tissue was 
deposited in different parts of the body. In no author that I have 
been able to consult have I found any similar cases. The earliest 
writer who advances the idea that icterus is hereditary is Mor- 



i 



CONTRIBUTIONS TO INFANTILE PATHOLOGY. 241 

gaeni : he says, '' In fifteen children of my own, who all became 
ywow after birth, and some of them in a considerable degree, 
the disorder was naturally carried off in every one of them of 
itself, and without the least assistance of art."'* An instance, 
however, is given by Underwood, of a lady, the mother of 
eleven diildren, nine of whom became jaundiced on the third 
day after birth, and all died within the first month ; the tenth 
died of the same disease in its sixth month ; and the eleventh 
became yellow on the third day after birth, appeared drowsy 
and sleepy, and was convulsed. '* On the following days the 
colour of the skin often varied, being sometimes of a deeper 
yellow, at other times refining nearly its natural colour ; the 
child, however, continued m the same state, but received nourish- 
ment, and sucked the breast of its mother, till within a few 
hours of its death, which took place on the ninth day." On 
dissection^ the liver was found nearly twice its natural size, 
and in some parts highly injected. The gall-bladder was 
nearly filled with bile of a deep yellow colour, and its ducts 
were permeable.f 

•It IS clear that this jaundice alluded to by Morgagni must 
be a very different affection from that* described by Under- 
wood; that it is in fact nothing more than the colora- 
tion of the skin that goes under the name of ^' the gum," 
a disease (if it deserve the term) that disappears with- 
out any treatment at all. Various causes have been as- 
signed for the occurrence of icterus in new-born childrcD. 
Morgagnij: thought that it arose from the supply of blood to 
the hver being diminished by the contraction of the umbilical 
vein having extended to the vena portse ; nearly the same 
opinion was held by Autenrieth,§ Chambon|| and Jahn 
thought that icterus was induced by pressure on the foetal 
cranium during labour. We well know that in adults inflamma- 
tion and abs(^ of the Hver frequently follow injury of the 
head ; but we have yet to learn that icterus is more common in 
children born after a labour complicated with contracted pelvis, 
or after the application of forceps, than in those born with the 
usual ease. BaumesV considers, as the cause of the disease, a 
collection of meconium or other irritating matters in the 
duodenum, either from the irritation excited producing spasm 
of the ductus communis choledochus, or from their actual 
quantity, obstructing by mechanical pressure that portion of 



* Lib. ill'.. Lit. 48, Art. 60. 

t On Diseases of Children, 7tb Edition, p. 31. 

t De Sedibus et Causis Alorborum, Epist. 48, Art. 60, 

§ Observationes Pathologies. 

II Ueber Kinderkrankheiten, Bd. i. Abthl. i. 

% M^moire sur Tlctire des Nouveaux-nes. 

2h 



242 CONTEIBUTIONS TO INFANTILE PATHOLOGY. 

the duct which runs between the coats of the duodenum. 
Rosenstein* says, " As to the causes of jaundice, we shall find 
them to be such which effect a stoppage in the channels that 
carry the gall or bile from the liver. Therefore slime, or 
glutmous liquids, may cause the jaundice in new-born children 
by shutting up this opening " (the aperture of the duct. com. 
cbol.) He thinks also that lumps of curdled milk or pap might 
have the same effect. It has been remarked both by Rosenstein 
and Tissot, that as the duct. com. chol. runs for a space between 
the tunics of the duodenum, griping, causing contraction of 
the muscular layer of the intestine, will produce constriction of 
the canal, showing how very easily the passage of the bile into 
the intestine may be obstructed. Various other causes hare 
been assigned by different authors, e. g. invagination of the 
duct. com. chol. (Fabricius Hildanus) ; sudden chilling of the 
body (Boer. Wendt. Joerg.) ; improper nourishment (Cams 
Levret et alii). There can be no doubt that we must regard 
obstruction of the duct. com. chol. as the cause of icterus : it 
is inunaterial whether the obstruction arise from spasm, pres- 
sure, or viscidity of the secreted bile ; if it be from absence or 
imperforation of the dtict, then we may look upon the affection 
as mevitably fatal, although in the second case above related we 
have a singular instance of a child having lived for six months 
without bile ducts. The absence of a gall-bladder (provided 
the ducts are present) need not be regarded as a certainly fatal 
malformation, any more than the absence of a urinary bladder, 
for they both apparently serve merely as the passive recipients 
of their respective secretions, until the proper time arrives for 
their expulsion. 

From the circumstance of very many children becoming more 
or less yellow soon after birth, and from the coloration of the 
skin being unattended by any symptom indicative of functional 
derangement, and disappearing without the help of art, many 
practitioners are inchned to regard this yellowness as an appear- 
ance as natural to the healthy child as desquamation of its cuticle. 
We must, however, consider this yellowness as a morbid appear- 
ance, but perhaps not always pathognomonic of hepatic derange- 
ment. When it is so, we should expect to find the coloration 
universal and uniform ; but at times we see it confined to the face, 
to the trunk, to the extremities, or perhaps to one extremity 
only ; disappearing in one part of the body suddenly, to reappear 
in another. In this affection the conjunctiva and nails frequently 
present no discoloration, nor are the stools of the clay-colour so 
constantly observed in jaundice from derangement of the hver. 
** Jaundice in children," says Underwood, " seems always to 
have been improperly conceived of. Those who have written on 

• Rosenstein on Diseases of Children, trans, by Spernuan, p. 200. 



CONTRIBUTIONS TO INFANTILE PATHOLOGY. 243 

children*s diseases have usually passed it over in silence, whilst 
others have considered it rather a serious complaint, and have 
, prescribed as for the jaundice of adults. On the other hand, 
nurses have usually accounted the yellowness that appears about 
the third day after birth, if unusually deep (termed by some the 
* yellow gum'), as the true jaundice. Certainly neither of these 
opinions is just ; this.(i. e. the true jaundice) is easily distinguished 
from the common yellowness by the tunica albuginea being 
always (?) very yellow, but the nails are not tinged." The ob- 
servations made above being corroborated by so high an autho- 
rity, I think we are warranted in concluding that the affection 
known under the term " icterus mitis" or " yellow gum," strictly 
80 called, does not invariably depend on disturbance of the 
hepatic function. But when icterus arises from disordered secre- 
tion of bile, the coloration is in general universal and uniform, is 
accompanied with symptoms of derangement of the digestive func- 
tions, e. g, flatulence, vomiting, griping, and clay-coloured stools, 
occasionally also with fits or spasms ; and on dissection the colora- 
tion is found not confined to the skin only, but extending to the 
subjacent tissues and most of the internal organs. Among the 
cases above related there was in one coma, in another vomiting, in a 
third diarrhoBa, and in all the Ught-coloured stools, with yellow- 
ness, not only of the skin, but also of most of the viscera. There 
was, too, another symptom, unusual, and of more importance and 
danger, viz. the umbilical hemorrhage. This probably arose from 
blood being continually poured into the liver, and bile being 
secreted, but finding no exit, the organ became highly congested, 
and the most ready passage through which it could free itself 
bemg the umbilical vein, blood mixed with bile accordingly 
escaped through that canal. The hepatic vein might for a time 
serve to carry off the superfluous fluids from the hver, but ulti- 
mately, when the congestion increased, it alone proved insufli- 
dent. We can thus easily explain the yellowness of all the 
tissues, for we may suppose that the bile, unable to escape, either 
broke down or permeated the fine tunic of the minute venous 
origins, and was thus conveyed by the hepatic veins into the 
general circulatory system. In one of the cases above related, 
the blood that escaped from the umbilicus coloured the linen 
deeply with the tinge of bile, proving that this fluid had entered 
the circulation, which it must have done directly, as it was im- 
possible that in any of the preceding cases it could first have 
been taken up by the absorbents from the intestinal tube. Were 
I again to meet with cases similar to the above, I should adopt a 
different mode of treatment, on the presumption of course that 
the obstruction was not immovable. It appears to ine that the 
administration of mercurials is only calculated to increase the 
mischief, for they excite the secreting functions of the liver to 
greater activity, and bile, which cannot escape, is more abun- 



244 CONTRIBUTIONS TO INFANTILE PATHOLOGY. 

dantly formed. We ought to endeavour as far as possible to 
cause relaxation of the ducts. This object would be attained hj 
the application of leeches, the use of the warm bath, with anti- 
monial or ipecacuan wine given in nauseating doses only ; for 
where there is tendency to umbiUcal hemorrhage an emetic might 
be productive of disastrous consequences. If me child appeared 
to be much griped, we might presume that the obstruction to the 
passage of the bile arose from the duct. com. choledochus being 
constricted by contraction of the intestine ; opium and aperients 
would then be beneficial. 

4 Picaudy Place, July 12, 1844. 



Practical Observations on some of the Chronic {or Functioned 
Diseases of the Stomach, S^c. S^c. By William Strange, 
M. D., M.R.C.S. Edin., Surgeon to the Ashton-under-Lyne 
Dispensary. 

(Continued from No. III., p. 172.) ' 

Andral has pointed out a variety of morbid irritation of the 
stomach, ** embarras gastrique,*' in which purgatives with eme- 
tics are extremely useful, and which indeed appears not to be 
amenable to any other kind of treatment, Mr Langston Parker* 
also relates cases in which all remedies failed to give reUef until 
antimonial emetics were administered. Immense accumulations 
of secreted matters were evacuated, and the symptoms imme- 
diately disappeared. In dealing, however, with every case of 
morbid irritation of the stomach, we must be careful to distin- 
guish the original lesion which has preceded the present symp- 
toms ; for unless this be done, no treatment will be successful. 
Looking upon most kinds of morbid irritation of the stomach as 
originating in a want of tonic contractility of that organ, I be- 
lieve that there are in reality very few cases which can be 
satisfactorily terminated by this simple mode of treatment. The 
cases which appear to me to be properly treated by active 
purgatives with emetics are those of recent standing, where 
there have been errors of diet, principally in regard to quantity ; 
as where the meals succeed each other too quickly, without a 
sufficient amount of muscular exercise intervening. In such 
cases the tongue is loaded with a thick yellow fur, the counte- 
nance is puffy or sallow, the conjunctiva jaundiced, the bowels 
are confined, with whitish scanty motions, or the evacuations 
may be loose and dark coloured. The pulse is generally slow, 
full, and compressible. These symptoms depend upon conges- 
tion of an active kind both of the liver and stomach, to which 

• The Stomach in its Morbid States. 1838. 



CHRONIC DISEASES OF THE STOMACH. 245 

tlie morbid secretions are of course owing. Whatever clears 

away the accumulated secreted matters, and unloads the venous 

system of the whole chylopoietic viscera, will therefore relieve 

the symptoms at any time, hence the constant recourse had by 

free uvers to drastic purgatives ; but a cure can onlv be effected 

by a complete change in the dietetic management of the patient. 

There is another and in some places much more frequent form 

of morbid gastric irritation to be met with, which is by no means 

so amenable to the evacuant treatment, '' par en haut et par en 

has," so useful in the former kind. Persons employed in 

crotfded workshops, such as tailors, milliners, confectioners, 

the attendants in many kinds of sale-shops, and the work-people 

of our silk and cotton factories, are its chief victims. There is 

equally a state of congestive irritation of the stomach, and often 

of the liver and the other abdominal viscera, in these as in the 

former cases ; but the symptoms are all of a passive kind, and 

lead us to suppose that not a hypersemic or congesto-inflamma- 

tory action, but a torpidity or a dynamic state of the motor 

powers of these organs is the proximate cause of the mischief. 

It would be folly to treat these cases with active evacuants, 
such as purgatives and emetics. The general an»mic and 
often emaciated appearance of the face and form, accompanied* 
with want of appetite, languor, and debility, shows that an im- 
proved state of the blood and motor powers is required. Guided 
by these considerations, I have found that gentle laxatives with 
tonics, as the pil. forr. c. aloe., and a mixture composed of a 
vegetable bitter, as infus. calumbaB, with the hydriodate of potash, 
with once or twice a mild mercurial purge to stimulate the liver, 
prove the best treatment. 

Such cases, when they occur in young females, are often com- 
plicated with chlorotic symptoms, and other indications of de- 
ranged menstrual function, palpitation of the heart, sick head- 
ach, pain in the loins, &c., and are signally benefited by small 
doses of iodine, as in the preceding formula ; replaced after a 
time by the sulphate, muriated tincture, or citrate of iron, as 
shall best suit the individual case. 

Another form of atonic morbid irritation of the stomach is 
that which almost always succeeds to excessive hemorrhages or 
other evacuations, to menorrhagia of long standing, and to de- 
bUitating diseases. There can be no doubt that these cases 
admit of no other treatment than the direct tonic plan carefully 
executed ; and every means of throwing nutritious substances 
into the circulation must be used. It is here that iron may be 
said to act as a real specific, as, by increasing the amount of the 
red particles of the blood, it gives tone to the enfeebled and 
softened parenchyma of the organs. But it is to the dietetic 
and regiminal management that we are to look for permanent 
amendment in those very common and troublesome disorders. 



246 CHRONIC DISEASES OF THE STOMACH. 

I do not here make mention of the various means and appliances, 
such as change of air, drinking mineral waters, travellmg, out- 
door exercise, &c,, which only the wealthy, or at least those in 
easy circumstances, can command. My experience of gastric 
disorders has been principally acquired at the bedside of the 
operative, and it is for his benefit chiefly that I write. 

Before we can devise any change for the better in the 
hygienic management of the operative classes, we must take a 
survey of the circumstances, physical and domestic, by whidi 
they are surrounded, and wluch may operate as a cause of the 
frequent occurrence of atony and morbid irritation of the sto- 
mach amongst them. 

I am far from being wishful to recruit the ranks of those who 
have written and spoken so much about the baneful effects upon 
the health produced by factory employment, and of the nume- 
rous diseases peculiar to this class of work-people; and I 
believe that extensive observation enables me to assert, that 
there is no peculiar disease, nor peculiarly prevalent disease, 
amongst the workers in the factories. Indeed, how should there 
be ? We know that the same physical causes which are sup- 
posed to operate so detrimentally in a cotton factory, exist and 
act in many other localities; in fact, in all where numbers of 
human beings are densely crowded together. These causes are, 
confinement in an unvarying temperature, sometimes a rather 
close, and in one instance a very elevated one ; insufficient ven- 
tilation ; in some rooms dust and bad smells ; rather long hours 
of work, without any great muscular exertion. 

Mr Chad wick* has cited instances which came out before tlie 
commissioners for inquiring into the sanitary condition of the 
labouring population of Great Britain, where 150 tailors worked 
twelve hours a-day in a room many times smaller and worse 
ventilated than the most unwholesome room in any cotton factory 
in Lancashire. The crowding of milliners, too, in close garrets 
in London, for twelve, sixteen, or even twenty-four hours to- 
gether, is never equalled in any factory. Many kinds of work- 
shops, prisons, and public schools are not better. 

But notwithstanding that I cannot admit that any peculiar 
disease, nor peculiar form of disease, is generated by factory 
labour any more than by any other kind of employment in 
which the workpeople are equally crowded, it is very evident 
that almost all diseases, and the constitution also, receive a very 
considerable modification by the action of certain causes upon 
the factory population and all that are similarly situated. A 
glance at the dense masses of young people, as they issue from 
a cotton factory, will strike the stranger with a vivid sense of the 
difference between their pallid cheeks and flabby musdes, and 

* Report on the Sanitary Condition of the Working Population of Great Britain. 



CHRONIC DISEASES OF THE STOMACH. 247 

the robust, rosy, and firm appearance of those employed in out- 
door labour in the country. If we trace the cause of this differ- 
ence, we shall discover the reason why gastric disorders are so 
much more frequent amongst the former than amongst the latter 
class of operatives. Every thing shows a want of tone or firmness 
of the general tissues of the body in those whose employment, in 
the midst of large towns, confines them many hours of the day 
in a close unvarying temperature, such as that of most factories 
and other workshops; the air, surcharged with exhalations, 
both from the overheated bodies of the operatives, and from the 
greasy machinery, &c., is, in consequence of too often insufficient 
ventilation, breathed over and over again without being com- 
pletely changed. The muscles of the body become less consis- 
tent and tense, and consequently contract less vigorously ; the 
skin is relaxed by the warmth of the atmosphere ; the venous 
circulation becomes languid, and the capillaries transmit the 
red particles of the blood more slowly and in less quantity ; 
hence the pallor. As a natural consequence of this state of the 
saperfidal circulation, the blood returns in less quantity to the 
right side of the heart, and when sent to the lungs, not there 
meeting with a sufficient stimulus in the contaminated air inspired, 
18 imperfectly oxygenized, and therefore proves an insufficient 
stimulus to the left ventricle. Hence arises the weak and irri- 
table pulse, the extended contractions but weakened impulse of 
the heart. The muscular substance, as 1 believe, in many in- 
stances becoming softened, favours the development of dilatation 
of the right side, so often accompanying the forms of disease 
above described. 

We shall not deal too much in hypothesis, if we contend that 
from the operation of the above causes, and the disordered 
nutrition which is thereby secondarily induced, every tissue of 
the body, the parenchyma of all the organs, becomes lax, 
softened, and, to use a mechanical phrase, disintegrated; and by 
consequence those vital properties which depend upon the close 
aggregation of their constituent particles, viz. tonicity and 
muscular contractility, become weakened and impaired. 

That this very evident though not visible change in the 
tissues of the body really takes place in those forms of atony 
and morbid irritability of the stomach which I have described, is 
argued in a very masterly manner by Andral* in the following 
passage : — " Certes, c'est so fonder sur une raisonnable analogic, 
et ne point s'ecarter des lois d'une saine philosophic, que d'ad- 
mettre que, dans le cas ou les principaux agens de la vie, le sang 
etle sys&me nerveux, ne nourrissent et n'excitent plus suffisament 
les organes, la force toute vitale d'agregation par laquelle sont 
rennies les differentes molecules des tissus vivans, cette force, 

* Clinique Medicale, 3enie Edit 



248 CHRONIC DISEASES OF THE STOMACH. 

dis-je, cesse d'avoir son intensity physiologiq[ue ; de 1^, diminu- 
tion de la cohesion de ces tissus, et leur ramollisseinent plus ou 
moins considerable, depuis le degre ou, comme on le dit yulgaire- 
ment, Uy a JldcdditS dee chairs, jusqu' a celui oil, pendant les 
caracteres de Torganization, le solide tend a redevenir liquide/' 

Dr C. J. B. Williams* has well remarked, that in proportion 
as the tonicity and vital contractility of organs become impaired, 
th^ir irritabifity increases; so that the^less susceptible they are 
of a normal action from a wholesome stimulus, the more readily 
do they take on an abnormal action by the appUcation of morbi- 
fic agents. Hence we may understand with what increased 
force unwholesome food, errors of diet, intemperate habits, &c., 
act upon the stomachs of those who are daily exposed to the 
causes of atony and general debility above described. 

I have observed that in most cases of morbid irritation the 
domestic management of the operative's fiamily powerfully 
seconds the morbific action of the factory or workroom. The 
methods of cooking are often very defective, too frequent use 
being made, of fatty, raw, and other indigestible substances. 
This, together with the very hasty manner m which the princi- 
pal meals — ^breakfast and dinner — are swallowed, soon superin- 
duces a degree of morbid irritation on the previously existing 
atonic condition of the digestive organs. 

To provide a remedy for the occurrence of these frequent 
disorders, then, we must entertain large views of the necessity 
for some kind of supervision of the arrangements as to venti- 
lation, site, size of rooms, and other sanitary conveniences of 
factories, workshops, and other public or quasi-public buildings. 
Without insisting upon too much magisterial interference with 
the employment of labour, it would be easy for an influential 
and well-educated officer to take care that proper arrangements 
should be made for the above sanitary purposes whenever new 
factories or similar places are erected ; and that improvements 
should be adopted m this department, so far as practicable, in 
existing ones. Free ventilation, with abstraction of all dust and 
a great deal of the smell, is perfectly attainable, and is in many 
instances amply provided for ; and those manufacturers who 
have carried out these wholesome arrangements insist upon their 
practicabihty in almost every instance. 

On the part of the operatives themselves much might be done 
by improved domestic economy and temperance, and particularly 
by the establishment of pubUc baths at a cheap rate ; a luxury — 
I niight say a necessary one — ^possessed by few of the manufac- 
turing towns in the north of England. 

I would also suggest the adoption of the plan of increasing the 
length of the principal meal hours. Half an hour for breakfast 



* Principles of Medicine. 1543. 



CHRONIC DISEASES OF THE STOMACH. 249 

and an hour for dinner is not sufficient for those who have a 
considerable distance to go, as more than half of the time is fre- 
quently expended in going to and from the place of work. The 
meals are in consequence hastily swallowed, and muscular exercise 
is commenced too soon afterwards. By extending the time al- 
lowed for breakfast to three quarters of an hour and for dinner 
to an hour and a half, more time for a short rest would be ob- 
tained. The operatives would, no doubt, prefer to have this 
extra time after the labour of the day is done by curtailing the 
number of working hours ; into this question, however, 1 do not 
enter. I merely suggest an improvement in the regiminal 
management of the digestive organs. 

It is astonishing that, with so many popular works on diet and 
the management of health, lectures at mechanics' iustitutions, 
and other sources of information for all classes of people with 
which the present age teems, there should be such gross ignor- 
ance prevalent amongst the lower middle and working popula- 
tion. Entirely ignorant of the action of the different kinds of 
diet upon the system in sickness and health, they commit the 
most dangerous blunders. We must not reckon, therefore, upon 
their own good sense in the dietetic management of atony and 
morbid irritation of the stomach, but we must lay down for them 
an absolute diet-roll, and positively interdict all other articles of 
food whatever. We find that those who suffer from bad diges- 
tion, the women especially, in consequence of the pain which all 
heavy articles cause them, take little other sustenance than 
slops, such as tea, broth, gruel, &c., and these often in immense 
quantities. Nothing can be more hurtfill to the morbidly irri- 
table mucous membrane. The excessive distention completely 
paralyses the already adynamic muscular fibre, and the load lies 
undigested, until chemical changes from fermentation take place, 
which give rise to gaseous eructations, acid regurgitations, heart- 
burn, and other distressing feelings. A mild diet, principally 
composed of farinaceous articles in a solid form, I have always 
found most agreeable to the atonic state of the stomach in these 
disorders ; it may consist of rice, bread, sago, or tapioca pud- 
dings ; rice, milk, small quantities of good and well-seasoned 
broth ; and, after a while, of lean animal food in quantities not 
exceeding four ounces at once. Butter, cheese, jellies, and for 
the most part eggs, and all other highly azotized substances, 
should be entirely forbidden. 

8dy Acute morbid irritation, — It is to be lamented that medi- 
cal writers are too often chargeable with great laxity in the use 
of physiological terms, on the right appUcation of which depends 
the comprehension of their ideas by others in the sense in which 
their authors conceived them. We find the terms irritation, 
iiTitability, sensibility, morbid irritability, and morbid sensibility, 
continually used by authors of works on stomach diseases in the 

2i 



250 CHRONIC DISEASES OF THE STOMACH. 

fame sense and to describe the same state of the digestire organs ; 
and, on the other hand, many yer j different affections of these 
organs are comprehended nnder the same terms. An acute 
irntation of the stomach, in which it rejects or refnses to digest 
every article of food or drink, is too often designated as an ex- 
alted state of sensibility, although there may be no pain accom- 
|)anyiDg it ; thus leading the correct physiologist to suppose that 
the nervous system is the chief part implicated, when the proper 
expression would be acute morbid irritation ; meaning thereby, 
that the concord between the food as stimulus and the stomach 
as an irritable organ is destroyed, and that instead of a healthy 
action, digestion, taking place from the consentaneous operation 
of the two upon each other, a morbid action with acute symptoms 
results, in consequence of either the stimulus or the irritable 
organ having become deranged. 

For a morbid action of an irritable organ may be occasioned 
in three ways : 1st, The organ itself being sound, an unnatural 
stimulus may be applied, — ^as in the case of the stomach, food 
highly indigestible, or taken in too large quantities, or too often ; 
2d, 1 he stimulus being a natural one, the organ itself may be 
in a morbid state, atonic, congestive, inflammatory, &c., and 
therefore unable to act on the stimulus in a healthy manner ; 
and, 3d, Both the stimulus and the organ being in a healthy 
state, yet from idiosyncrasy, climate, age, &c., they may not be 
adapted to each other ; whence, in the case of the diet, it follows 
that nice discrimination and experience must be used. 

Acute morbid irritation of the stomach betrays itself by 
such symptoms as cannot easily be mistaken by an attentive 
praotitionor. There is acute pain in the stomach after taking 
any kind of food, which is not relieved until the latter passes 
out of that organ, which it often does by vomiting coming on 
either immediately or very soon after food has been taken ; 
sometimes such a spasmodic action ensues, that the smallest 

Cortion either of food or drink is instantly rejected, even 
efore it seems to have had time to enter the cardiac orifice. 
When the food is retained and pirtially digested, it is often 
forced prematurely out of the stomach ana small intestines, 
in consequence of the irritation which the imperfect chjme 
produces on the duodenum ; in this case the motions very 
much resemble the food which has been eaten. The boweb 
are, however, in a great majority of cases, obstinately confined, 
and then the reduction of this state is often the first harbinger 
of relief. Vomiting also occurs at uncertain int^ervals daring the 
d»y, the matters ejected being bilious, or composed of a guurv 
mucous fluid> sometimes in immense quantities. There is aim 
r^orgitation of acid matter, and occasionally, but rarely, of a 
taxless water (water-brash). The tongue* is very yariable in 
appearance, it being sometimes very clean, red, and moist ; or 



CHRONIC DISEASBB OF THE STOMACH. 251 

red and dry, having a baked appearance ; or brown and dry ; 
or moist and loaded with a thick yellow fur. The pulse is 
either very slow and full, or quick and thready, sometimes 
intermitting. The countenance sunk and haggard, exhibiting 
signs of suffering. This form of gastric disorder manifests 
great variability m the length of its attack and the severity of 
its symptoms. In some cases, such is the violence of the 
spasmodic action, and the disturbance of the circulatory, re- 
spiratory, and nervous systems, that almost instant death is 
threatened ; in others, the svmptoms, of a chronic and scarcely 
observable state, creep on from bad to worse, until digestion is 
iM$arcely performed at all, and extreme emaciation follows. 
This is often the case in those aggravated forms of dyspepsia, 
as they are called, to which I alluded in a former part of this 
paper ; viz., when the complaint begins with a simple state of 
atony or debility of the stomach, passing into a low chronic 
irritability in consequence of errors of diet or bad treatment, 
and thence into acute morbid irritation. 

The symptoms have also remarkable remissions. Some 
patients are exempt from any very distressing feelings for 
weeks or months together ; others have almost periodical re- 
missions and exacerbations which are relieved by vomiting a 
quantity of mucous fluid. In some instances there is more pain 
when the stomach is empty ; but when such is the case, I am 
inclined to consider the symptoms as more dependent upon a 
nenralgic or upon a congesto-inflammatory action, than upon a 
simple irritation of the mucous and muscular coats of the 
stomach. The two following cases will illustrate the foregoing 
observations. 

Case Ist. — ^A gentleman, convalescent from a subacute aitad^ of 
bronchitis and pneumonia, contrary to orders, indulged in a 
dinner of hashed veal before leaving his bed. In the middle 
of the night I was called to him, with word that he was in 
a dying state. I found him naked, wrapped up in blankets, 
sitting before a large fire, perspiring from every pore, and 
rolling about unable to speak from intense agony ; pressing 
upon the pit of the stomach, and making ineffectual efforts to 
vomit. The pulse was fluttering and not more than eight beats 
per minute ; respiration exceedingly short and difficult, as 
much so as in acute pleuritis. I instantly administered an 
emetic, whidi in less than an hour completely removed the 
symptoms. Such was the intensity of the constitutional irrita- 
tion in this case, that I believe death would have speedily 
ensued had not assistance been promptly rendered. What, 
may we suppose, was the state of stomach in this instance? 
Inflammatory action could scarcely have been induced, or it 
would not have vanished so immediately ; neither was vomiting 
excited until the emetic was given. Doubtless the veal acted 



252 CHRONIC DISEASES OF THE STOMACH. 

npon the stomach in its then adynamic state, the consequence 
of illness, as a foreign body, irritating the mucous membrane 
and the nerves to the alarming degree I witnessed. 

Case 2d, — A young woman of a highly sanguine tem- 
perament, nine days after a good delivery (the lochial dis- 
charge, which had been copious, having suddenly stopped), was 
seized with violent vomiting and purging, for which acet. 
plumbi and opium in small quantities were given, with reUef to 
the purging. The vomiting, however, continued without 
intermission for seven days ; every thing which waa taken — 
medicine, food, or drink — ^being rejected before it had remained 
in the stomach half a minute. The pulse was throughout the 
whole time unaltered ; there was no pain on pressing the 
epigastrium, only uneasiness when anything was taken. The 
tongue and fauces were vividly red throughout, clean, and with- 
out aphthae; in fact, there was no evidence of inflammatory 
action whatever. The strength was but little diminished, 
although for seven days not a particle of sustenance was 
retained. Saline draughts, acetate of lead, opium in substance, 
hydrocyanic acid, creasote, and calomel were all tried without 
any effect, as were also sinapisms to the stomach and to the 
feet. Large quantities of gruel, as a pint at once, were the 
first to rest on the stomach, after which the vomiting subsided. 

We can scarcely attribute these symptoms either to inflam- 
matory action or to irritating articles of food ; as in the one 
case more constitutional symptoms would have exhibited them- 
selves, and in the other the vomiting, by relieving the 
stomacli of the offending substance, would have very shortly 
cured itself. Most probably a congested state of the mucous 
membrane had taken place, in consequence of the cessation of 
the menstrual flux, particularly as large quantities of mucus 
were ejected from the stomach. 

There is a variety of acute irritation of the stomach which 
appears to be owing to a more passive kind of congestion. Con- 
finement in a close atmosphere, sedentary occupations, habitually 
inhaling mephitic odours, uneasiness of mind, pressure upon the 
epigastrium, and bad living, are the most frequent causes of this 
form of disorder. In these cases the tongue is generally very 
white, with red and elevated papillae underneath the thin fur ; 
the edges and tip more or less red, and sometimes indented. 
The breath is hot, with a bad odour ; there is almost total loss of 
appetite, or a craving only for very savoury and indigestible 
food. The muscular strength is much diminished, and the body 
emaciated. The urine is high coloured and scanty, and gene- 
rally deposits lithic acid, sometimes the ammoniacal salts. The 
bowels are often obstinately confined. With these patients di- 
gestion seldom takes place without more or less pain, though 
vomiting of food occurs only occasionally, and in an irregular 



CHRONIC DISEASES OF THE STOMACH. 253 

manner. Large quantities of food are secreted b^ the stomach, 
and rise in acid or acrid regurgitations, accompanied with flatus. 
There is also much gas voided along with the scanty stools. 
After this state of things has continued some time, various sym- 

Eathetic affections set in, such as neuralgic attacks of the stomach, 
eart, .face, or pericranium; sleeplessness, with starting and 
fearful dreams ; palpitating and epigastric pulsations, with irre- 
gularity of the heart's action ; disease of the kidneys, heart, or 
lungs. The following interesting case will exhibit the manner 
of invasion of some of these symptoms : — 

Case ^. — A schoolmsister, aged about 60 years, had long 
suffered from a slight degree ot dyspepsia, arising doubtless 
from the confinement consequent upon his occupation, he having 
formerly led a more active life. Within ten yards of the school- 
house ran an open sewer, into which a little higher up than his 
school a factory reservoir emptied itself, the hot water from 
which, rising in steam as it passed along, carried with it the 
gaseous exhalations of the sewer, the smell of which was most 
offensive. About the time of the more acute symptoms making 
their appearance, the patient experienced a great deal of anxiety 
and grief in consequence of the departure of his son as a mission- 
ary, along with the Rev. Mr Moffat, for Southern Africa. At 
this time he exhibited many of the characteristic symptoms of 
acute irritation of the stomach related above, viz., quick and 
irritable pulse, hot dry skin, tongue covered with a thin and very 
white fur, the red papillae appearing underneath. The epigas- 
trium, always uneasy, was intensely painful after taking any 
kind of solid food ; bowels obstinately confined ; face sunk and 
careworn; failure of the muscular strength, and emaciation. 
Vomiting was only occasionally present. Counter irritation, 
leeches, and other antiphlogistic treatment failed to give any 
marked relief ; purgatives, bismuth, and tonics were not more 
useful. The symptoms increased in severity, until after a while 
intense neuralgic pains of the stomach and face came on, the irri- 
tation from which afterwards gave rise to twitchings of the limbs 
and starting, so that he could scarcely be kept from rolling out 
of bed at night or falling from his chair. The stomach was now 
80 irritable, and affected with such severe paroxysms of pain, 
that I was obliged to restrict him to the very lightest food in 
small quantities, and eventually advise him to give up his school 
altogether, for which he had been long unfitted by bodily weakness 
and extreme depression of spirits. 

On exchanging the school for an out-door occupation, the 
symptoms of irritation gradually subsided ; he improved in ap- 
petite and flesh, and slept better ; but the neuralgia of the face 
attacked him several times afterwards, and only disappeared 
after a good deal of treatment. In this case almost all the 
varieties of gastric disorder which I have enumerated at the 



254 CHRONIC DISEASES OF THE STOMACH. 

beginning of this paper, as constituting the compound disease of 
dyspepsia, were present during some part of the attack. Com- 
mencing with an atonic and debilitated state of the organ, it 
gradually passed into a chronic state of morbid irritation ; then, 
on the accession of fresh causes of mischief, acute irritation, 
neuralgia, and perhaps some degree of chronic gastritis, suc- 
ceeded. 

In respect of the treatment of this disorder, nothing fixed or 
certain can be laid down for general adoption. All our remedies 
will often fail to give any marked relief; and when the disease 
has been of long standing, even the removal of the cause will 
not always speedily dissipate the symptoms. Regard must ever 
be had to the true pathological condition of the mucous mem- 
brane, so far as can be ascertained, and our remedies directed 
either against the disordered condition of the organ, or the errors 
of diet or offending ingesta, as the case may be. When called 
upon to allay urgent vomiting, if we can satisfy ourselves that 
there is a congested state of the mucous membrane bordering on 
inflammation, which will generally be indicated by a full and 
slow pulse, redness of the tongue and lips, and constipation, 
we may begin with leeching the epigastrium, followed oy sin- 
apisms, an emetic, and afterwards by purgatives of calomel and 
aloes, &c. If, on the other hand, the stomach and other diges- 
tive organs appear to suffer from a low and adynamic state of 
hyperaemia, where there is chronic vomiting only, with acid 
eructations or water-brash, I have found the following formula 
useful: — 

'Be Bismuth trisnit., 

Sodad bicarb, aa. 3i. 

Acid, hydrocyanic. gtt. xii. 

Infus. calumb. et cinnam. jvi. M. 
Half an ounce to be taken every two hours, with the pil. ferri 
c. aloe, every night. 

To allay vomiting in acute morbid irritation of the stomach 
many remedies are m daily use, but all too often fail to act satis- 
factorily. No great faith, so far as my experience goes, can be 
placed in creasote, hydrocyanic acid, acetate of lead, opium, 
effervescing draughts, &c., although each of them is sometimes 
successful, especially large doses of solid opium. Large doses 
of calomel, 6 or 8 grains, and sometimes small ones, as half a 
grain repeated every hour, frequently give great relief. Some 
articles of diet occasionally succeed when all medicines are re- 
jected, for instance gruel and water, in which a blackened toast 
has been soaked. The bowels must be unloaded in every caae. 
Dr Abercrombie relates a case from Dr Parry, in whidSi very 
small doses of aloes alone allayed a very obstinate Tomiting. 
The food, in small quantities, must be chosen according to our 
experience of each case. Tonics, cold sponging and bathing, are 



CUUABILITY OF HYDROCEPHALUS. 255 

useful in completing the cure. I have known the most aggra- 
Tated symptoms frequently removed by the patient going for a 
week to the seaside. 

(^To be continued,) 



On the Evidence for the ready Carability of the more acute Form of Hydro- 
cephalus in its earliest Stage, and the Practicability of the Diagnosis in the 
QeneraHty of Cases, By Alexander Harvey, M.D., Lecturer on the 
Institutes of Medicine in Marischal College and Univei'sity, Aberdeen. 

I PURPOSB in this second communication on the subject of h3'drocephaIus, 
to inquiit; wliether that disease, in its more acute form and in its earliest 
stage, is not much more generally amenable to active treatment than many 
suppose ; and whether the diagnosis of that form of it may not then be 
g^enerally made out with sufficient confidence to warrant active interference. 

Though perhaps unnecessary, after the qualified announcement now 
made, yet, to obviate misapprehension, I am anxious to avow, at the outset, 
my conviction, that there is a set of cases of hydrocephalus to which the 
following observations will not apply, t. e, tliat there are cases where the 
early symptoms are so obscure as to excite no suspicion of their real nature, 
and where the inflammation is from the first of so intractable a character, 
or the bodily habit of the patient so feeble, that active treatment can neither 
be well home, nor be expected to be of much avail. These cases are gene- 
rally somewhat slow in their progress, occur in connexion with inflamma- 
tion, era constitution of a decidedly strumous character, and often supervene 
on other diseases at their close or during their course. How far all the cases 
to which this general description applies are not to be either recognised or 
cured in their earliest stage, I do not now inquire ; but setting the whole of 
them aside, there still remains a large number of others which may fairly 
be brought under consideration in reference to the present inquiry. 

I. The acute hydrocephalus being an inflammatory disease, or one ** so 
nearly resembling inflammation as to demand the same practical considera- 
tion," analogy would lead us to expect that, although (as ample experience 
shows) it quickly passes into a state which is nearly beyond the power of 
remedies, it should nevertheless in its early stage be equally amenable to 
them as any other incipient inflammatory disorder. This expectation, 
however, to be satisfactory, must be tested by experience, because we cannot 
beforehuid be certain that there is not some peculiarity in that inflamma- 
tion, or in the parts affected by it, to render it from the first neai'ly if not 
quite incurable. 

Is that expectation, then, justified by experience ! 

In regard to this question, it is obvious that we are met at the very 
outset by a serious difficulty. As there is no single symptom, nor any 
combination of symptoms, attending the early stage of the disease, absolutely 
pathognomonic, we can never be certain that any given case or set of cases, 
which seemed to be examples of it, and have recovered under active treat- 
ment, either were of the nature they appeared to be, or have been cured by 
the remedies made use of. Therefore, in considering the question proposed, 
the kind of evidence which the nature of the case admits of must be care- 
fully borne in mind. Demonstrative it cannot possibly be. It can never 



256 CURABILITY OF HYDROpEI^HALUS. 

amount to any thing higher than probability. But ^'probable evidence 
admits of degrees, and of all variety of them, from the highest moral cer- 
tainty to the very lowest presumption." 

Keeping this in mind, it may next be stated that the only evidence which 
we either have or can have for the curability of this disease in its early 
stage, is,— 

1*/, That cases have terminated favourably which presented symptoms, 
both local and general, precisely similar to those aitending the early stage 
of others which have ended in &tal hydrocephalus. 

2<%, That the blood drawn from the arm, in those that recovered, has 
been both sizy and contracted (i, e. characteristic of inflammatory disease), 
and easUy distinguishable from the blood of incipient fevers, the crassamen- 
tum of which is not sizy, and is often comparatively loose. 

Qdly^ That the convalescence has been so rapid and complete as to indi- 
cate that an inflammatory disease has been cut short; whereas febrile 
disease of any kind, not dependent on inflammation, does not admit (as a 
general feet at least) of being so quickly arrested by remedies.* 

Such and such alone is the kind of evidence by which the question as to 
the curability of incipient hydrocephalus is to be determined or can be 
eolved. But indirect as it is, and liable to fallacy, yet, if based on a suffi- 
cient number of cases, and setting aside many of these as spurious, it may 
still be strong enough and ample enough to satisfy every reasonable mind. 

What, now, is the positive testimony of pi*actical physicians, of approved 
judgment and extensive experience, in regard to the question at issue ! 

Dr Abercrombiet says, " There is no doubt that many cases have recov- 
ered which exhibited all the usual symptoms of hydrocephalus," several 
examples of which are given by him in the sequel of his work (p. 146). 
And again, " By active treatment, adopted with decision at an early period, 
we have the prospect of arresting its progress in a considerable proportion of 
cases." (P. 145.) 

Dr Watson, j: although he does not give any formal statement on the 
subject, suited for quotation, yet delivers his sentiments in such a way as 
plainly implies his persuasion of the great efficacy of active treatment when 
had recourse to in the early stage ot hydrocephalus ; and, inter aliOy while 
he states that " when once it is fairly established, many more die of it 
than recover," he adds that " our chance of saving the patient's life by ap- 
propriate treatment is alwa^'S greater in proportion as the complaint, or 
the tendency to the complaint, is detected early." (P. 428). And again, 
after attending to seventy-six cases of the disease occurring in the practice 
of difierent physicians named by him, and ot which nineteen recovered, he 
goes on to observe that "the cases in which recovery took place were 
mostly those in which antiphlogistic measures were adopted early." 
(P. 434). 

Dr Alison's testimony is even more satisfactory, and is much more ex- 
plicitly delivered. After remarking that " the prognosis is always to be 
regarded as doubtful, and in all the more complex and insidious cases, or in 
cases which are not recognised or neglected in the commencementy as very 
unfavourable," he says, ^many well-marked cases, however, particularly 



• Brit, and For. Med. Rev., vol. iii. p. 307. — Watson's Lectures on the Prac. 
of Physic, vol. i. p. 425. 

t Path, and Prac Researches on the Brain. 3d Edition. J Op. citat. 



CURABILITY OF HYDROCEPHALUS. 257 

• 
those in which the early symptoms are most distinct and characteristic, 
ntbside complelely under active depletion; particularly full and repeated 
blood-letting and purging." (Outlines of Pathology and Practice of Medi- 
cine, p. 944.) And he expresses himself still more strongly in an article 
(of which he is understood to he the writer) in the third volume of the 
British and Foreign Medical Review ; where, after commenting on Dr 
Abercromhie's description of the more frequent form of this disease, he re- 
marks that *^ a good deal of experience has convinced us, that if this com- 
bination of symptoms is seen witliin the first two days, and met by full and 
repeated blood>letting (from the arm, if the patient is above three years of 
age) and free purging, the greater number of such cases will do well,** What 
enhances the value of this remark is the distinct recognition which accom- 
panies it of the whole circumstances necessary to be taken into account in 
judging of the cases spoken of. " It is very important to observe (says Dr 
Alison) that the blood drawn from the arm is very often both sizy and 
contracted, and easily distinguished from the blood of incipient fever, the 
crassamentum of which is comparatively flabby ;" and again, that " the con- 
valescence is so rapid and complete as to indicate unequivocally that an 
inflammatory disease had been cut short." (P. 307.) 

But perhaps the most remaikable testimony of any on this subject is 
that borne by the late Dr Maxwell* of Dumfries, who, according to his 
own statement, lost only one patient out of three in upwards of ninety cases. 
His practice was bold and hazardous in the extreme, consisting of blood- 
letting, and generally repeated blood-letting in the horizontal position, till 
the pulse could not be felt, and insensibility, lasting occasionally for some 
hours, was produced ; but " in upwards of ninety cases (to use his own 
words) that have been treated in this way, above sixty have recovered. In 
most of these I Imve had the assistance (he adds) of one or more medical 
gentlemen of this place." (P. 13.) 

Had tliis testimony been more circumstantially given, it would be easier 
to judge of its precise value. Dr Maxwell, indeed, candidly allows the 
difficulty of determining how far the sixty cases that recovered were ex- 
amples of hydrocephalus ; but he remarks, that as they " did in almost every 
symptom resemble those that terminated fatally, we may be allowed to infer 
that the disease in both was the same." (P. 14.) He does not, however, 
mention the period at which the successful cases were brought under treat- 
ment, nor does he say anything regarding the appearance of the blood drawn 
or the rapidity of the recovery — important elements in judguig of the pro- 
bable nature of the cases. Still, considering the importance of the criterion 
stated by him as the ground of his opinion ; his extensive opportunities of 
acquainting himself with this class of ciiscs, as is obvious from his observa- 
tion, not so much of the successful ones, but of iwenty-seven fjUal cases 
after his adoption of his peculiar plan of treatment, and of twenty-five other 
fatal cases previously ; and considering also his indirect appeal to his pro- 
fessional brethren for the accuracy of his observations, and the correctness 
of his statements, — 1 think it were unreasonable not to allow that a lai^e 
proportion of the patients that recovered had been really affected with hy- 
drocephalus. 

An impoi-tant qualification of these general statements is made by Dr 
Abercrombie, and acquiesced in by all practical writere, viz., " that the 
more the cases approach to the character of active inflammation, our pros- 

• Edin. Med. and Surg. Journal, vol. xxii. 

2k 



258 CURABILITY OF HYDROCEPHALUS. 

pect of cutting them short will he the greater ; and that the more they 
partake of the low scrofulous inflammation^ it will he the less." (P. 145.) 
In regard to these last, however, it is to he ohserved that the symptoms are 
very often, perhaps very generally, ohscure ; and Dr Alison makes this im- 
portant practical observation regarding them, that ^* in many such cases the 
main remedy, viz. blood-letting, is ineffectual, only because the disease is 
not recognised, at least with such confidence as to secure its energetic 
employment in the early stage " (Brit, and For. Med. Rev., p. 808), — an 
observation which, if correct, enliances the impoi-tance of another made by 
Dr Watson, that ** we are bound to act, in some instances, upon very slight 
indications ; as when, for example, we perceive what we think threatenings 
of acute hydrocephalus in a scrofulous child, or in a child belonging to a 
family in which others have already been cut off by tliat disorder." (Op. 
citat, p. 428.) 

Such is the testimony borne by the writers now quoted to the ready 
curability of the acute hydrocephalus in its earliest stage under active 
treatment. Their evidence is, I humbly submit, quite satisfactory, at 
hast in a practical point of view. It may be insufl&cient to prove abso- 
lutely the truth of the proposition that the disease is thus curable, or even 
that it is curable at all ; but such kind of proof is not available to us, and in 
this point of view the question at issue can never be affirmatively deter- 
mined. The necessities of practice, however, imperatively demand an 
affirmative solution of the question, if possible, and require us to he satisfied 
with evidence far short of demonstrative. Allowing, then, that the evidence 
adduced has no higher character tlian probability, I contend, nevertheless, 
that it amounts to probability of a very strong kind, and that, relying on it, 
and in reference to the pi-actical object for which it is adduced, we may 
confidently affirm of the acute hydrocephalus, that in its more active form, 
and in its earliest stage, it is readily amenable to active treatment. 

At all events, it is perfectly clear that the inference now drawn from it 
is not in the least affected by any amount of experience of the mortality 
from this disease, which has been coextensive with a feeble and undecided 
plan of treatment in its earliest stage; and that the conviction of its incura- 
bility (whether absolute or comparative), in so far as it is founded on 
such experience, is positively fallacious. Such experience is indeed valu- 
able, as showing the fatal tendency of the disease when left to itself or 
inadequately treated, but is of no value as bearing on the qu( stion, whether 
under proper treatment it may not, within the particular period specified, 
be equally amenable to remedies as any other acute inflammatory disorder. 
And it may be, in point of fact (I hope it is not), the general experience of 
the profession, tliat of those affected with hydrocephalus, and seen even from 
the commencement, many more die of it than recover, — nay, that the far 
greater part perisli ; but it does not therefore follow that such must needs be 
the case. 

I say it does not follow that such must needs be the case. The fact 
may be so, but the inference from it this — ^not tliat the disease is incur- 
able, but that the proper remedies are not employed, or that they are too 
long deferred, or, if used early, tliat they are not carried sufficiently far. 
" There is too much reason to apprehend (says Dr Joy*), that many 
children have fallen victims, not so much to the incurable nature of their 
case, as to the indecision of their medical attendant." To the same purpose 

* Cjc. of Pract. Med. (art. Hydrocephalus), vol. ii. p. 467. 



CURABILITY OF HYDROCEPHALUS. 269 

are the following remarks of Dr Cheyne :* — ^** Every disease, whose tendency 
is to destroy a vital organ, becomes in unskilful hands an incurable disease. 
Thus, for example, croup may be considered incurable. * * *, When we 
dally with that disease in its first stage, not one in twenty will recover ; where- 
as, if the treatment in the first stage be judicious, there will not be one death 
in twenty, nor perhaps in a hundred. It is not long since physicians were 
more ignorant of the nature of croup than they are now of hydroceplialus ; 
the day is perhaps not distant when, better understanding the nature and 
import of its early symptoms, hydrocephalus also may lose much of its 
danger. In this inquiry some progress has already been made." We 
often, indeed, take immoderate credit to ourselves for curing our patients, 
when in truth their recovery has been owing to the natural tendency of 
their disorder to a favourable tennination, and may even have taken 
place in spite of measures directly calculated to defeat that tendency. 
But it is worth while considering whether, when they die, we do not 
oftener than is really just ascribe their death to an inevitable tendency in 
the disease to a fatal result, — a tendency which may have been quite real 
and very strong, but so far from inevitable that it might have been obvi- 
ated by us. And what if this mistake is not seldom committed in fatal 
cases of hydrocephalus \ The question deserves, at least once for all, to be 
seriously put to himself, and deliberately considered and answered, by 
every one. 

If, after all, the evidence now brought forwai-d shall appear to any to 
be unsatisfactory, I would just urge upon their attentive consideration, 
that there is a very great practical difference between a full satiafactwn of 
the truth of the proposition advanced on the faith of it, and a satisfaction 
of the contrary. The middle state of mind between the two consists in a 
serious apprehension that it may be true, joined with a doubt whether it 
is so. And this, upon the best judgment I am able to form, is as far 
towards speculative disbelief of it as any one can at all be supposed to go, 
who has in any tolerable measure considered the evidence now laid before 
him. Now, a serious apprehension that it may bo true that the acute 
hydrocephalus is as curable as has been represented, lays us under the 
strictest obligations of a serious regard to it, — a regard the same, or in 
many respects nearly the same, with wliat a full conviction of its truth 
would lay us under.t 

It will not, I hope, be inferred from any thing now stated, that I 
entertain such an extravagant notion of the curability of the more acute 
form of hydrocephalus in its earliest stage, as to imagine that every case 
of it brought under treatment at that period may be saved. But there 
is a great practical difference between saving sixty out of ninety cases, as 
Dr Maxwell thought he did, and losing sixty out of ninety, — ^nay, between 
saving the majority of such cases and losing the majority of them. That 
a majority of them at least may be saved, I have no hesitation in avowing 
my belief. And if I have succeeded in convincing any one of this, who 
before was otherwise persuaded, and in inducing him to resolve on treat- 
ing such cases, when he meets with them, with prompitudey decisUmy and 
energy, the object of this paper will be answered. 

II. The practical value of the conclusion arrived at in regard to the 



• Essays on Hydrocephalus A cuius, 2d Edition, p. 53. 
t Bulter's Analogy, part ii. conclusion. 



260 CURABILITY OF HYDROCEPHALUS. 

curability of the acute hydrocephalus turns entirely on the practicability 
of making out the diagnosis of the disease in its earliest stage. 

In judging of the question how &r this is practicable in the generality 
of cases, it is necessary to consider, in the fii-st instance, on what grounds 
we are entitled in any case at its outset to infer the existence of the disease. 
>iow, it is sufficiently clear from experience, that this is to be done not by 
trusting to pathognomonics of any kind, but simply by attention to a 
certain combination and succession of symptoms, and to the nature and 
import of certsiin symptoms which have been observed to attend the com* 
mencemcnt of cases which have ended in fatal hydrocephalus. 

But these symptoms, it is to be observed, form a part only, and that a 
small part, of those which constitute the whole phenomena and tlie 
nosological definition of the disease ; and the same or similar symptoms 
have often been observed to attend the early stage of other cases which 
have turned out not to be hydrocephalus. At this period, therefore, we 
obviously cannot pronounce so confidently on the nature of a case, as we 
may be able to do on its reaching even the stage next In advance, when 
other symptoms may exist more distinctly indicative of affection of the 
functions of the brain, or as we may be able to do on its favourable 
termination subsequently, under active treatment, without its ever having 
advanced to that stage, because, then, circumstances connected with its 
maimer of termination, and the effect of the remedies employed, must 
have occurred, and will be available to us in judging of what its nature 
was. 

Nevertheless, slender as may be the grounds of our diagnosis at the 
outset of a case, the obsei-vation of a set of symptoms exactly similar to 
those known to attend the early stage of h^'drocephalus, is sufficient, in a 
practical view, to justify our regarding them as dependent on that disease, 
and to demand the remedies for it. It is of no consequence that there is 
an equal or even a greater cliance of their being dependent on a different 
kind of morbid action, not requiring such remedies, unless it can bu 
shown, which I apprehend it cannot, that any injurious effects that 
might accrue from the unnecessary employment of those remedies would 
outweigh the risk of life incurred from their being delayed or declined 
should the case really be of the nature of hydrocephalus. And to wait 
till the progress of the case shall throw farther light on the nature of the 
symptoms, may be, and in a genuine case of hydrocephalus would 
probably be, to wait till such elucidation of them could be of no practical 
value. 

It cannot, therefore, in my judgment, be too strongly impressed on our 
minds, in reference to this class of cases, ** that certain symptoms, and seta 
of symptoms, are often invested with a practical importance hardly in* 
ferior to genera of disease, demanding and justifying the use of lenwdies 
in many cases where it is still uncertain of what disease they form a 
part ; — although, in all cases, it is of the utmost importance to obtain this 
knowledge as soon as possible, in order to understand the danger that is 
impending, and to acquire confidence in the remedies tliat are truly 
indicated,"* 

But, in truth, I apprehend that in very many, if not the greater part, 
of the more acute casecT of hydrocephalus, the diagnosis during the early 



• Brit, and For. Med. Rev., vol. iii. p. 303. 



CURABILITY OF HYDROCEPHALUS. 261 

stage is not an affieiir of such difficulty as the foregoing reasoning may 
seem to indicate. ''The diagnosis (says Dr Watson*) is really not so 
difficult as it has sometimes been represented." It may be that the 
phenomena of the disease have not been more accurately observed of late 
years than they were formerly ; but I am persuaded that, since the 
pathology of it has come to be better known, the nature and import of the 
symptoms, and their relative value and importance, have also come to be 
better understood, and that we are now in a position to interpret them 
more accurately than our predecessors were forty or fifty years ago. 

In reference to this, I may recall attention to the practical importance 
attached by Dr Cheyne to an inquiry into the nature and import of the 
early symptoms, and to his statements, made in 1819, that ^in this 
inquiry some progress has already been made ; " and I think it may be 
confidently asserted that Dr Cheyne's own investigations, and the previous 
and subsequent ones of other practical physicians, and particularly of 
Dr Abercrombie, have tended greatly to accomplish the objects of that 
inquiry, and have gone far in enabling us to fix more confidently than 
before on the diagnostics by which this disease is to be recognised iu 
its first stage, and discriminated from others for which it is liable to be 
mistaken. 

It is true that there is considerable variety in the early symptoms of not 
ft few cases of this disease, corresponding to a certain extent, though far from 
generally, to real difierences in the character and perhaps in the seat of the 
inflammatory action with which they are connected ; and Dr Abercrombie 
has rendered a real service to practical medicine by accurately describing and 
arranging those varieties, and thereby facilitating their diagnosis ; but there 
is a large number of cases, of more frequent occurrence too than any otbera, 
and more acute and tractable in their cliaracter, which are attended by a 
tolerably definite, and uniform, and well-marked concourse of symptoms. 

These symptoms are — sharp, shooting, or remitting pains of head, impa- 
tience of light and sound, sickness and vomiting from slight causes, with 
great aggravation of the uneasy feelings on assuming the erect posture, 
and fever of various degree, but without the usual general oppression or 
depression of idiopathic fever, or of the contagious exanthemata. The pulse 
is firm, often peculiarly sharp, but seldom very frequent, and in some cases 
almost from the beginning it is slower than natural. In very many cases 
the bowels are remarkably costive and obstinate.t Of these symptoms, 
perhaps the most important are the sharp shooting pains of head and the 
vomiting from slight causes, with the aggravation of both on assuming the 
erect posture. The former are well described by Dr Alisonj: as being 
" often marked by occasional twinges or stounds oi peculiar intensitt/y causing 
the patient to scream out ; and the vomiting as extending to all, or almost 
all, the ingesta." 

And these two symptoms have of late years derived peculiar significancy 
and importance as indicative of the incipient stage of hydrocephalus, — thu 
former in consequence of its being now clearly ascertained that the morbid 
action constituting thai disease is of the nature of inflammation, of which, 
as occurring in internal oi*gans, pain is a very important symptom ; and the 

• Op. citat. p. 420. 
' + Alison's Outlines of Path, and Pr. of Med., p. 338. CuUen's First Lines, ed. 
by Collen and Gregory, voL ii. p. 323. 
X Brit, and For. Med. Rev., vol. ill. p* 307. 



262 CURABILITY OF HYDROCEPHALUS. 

latter, as being now known to physiologists to be an affection, not of the sto- 
mach (and therefore not necessarily connected with disorder of that viscus), 
but of various muscles, excited, through the spinal cord, by a reflex or 
sympathetic action, originating probably in the medulla oblongata, and 
remarkably liable to be excited by physical changes in the brain itself. 

Of the two symptoms mentioned as the most important, the pain is oIk 
viously the more important ; and when existing singly, and having the 
peculiar character above stated, is sufficient of itself to excite suspicion of 
the presence of the disease, and to warrant the remedies for it. The vomit- 
ing is sometimes less observable, or is even wanting ; but it will not seldom 
be observed in this case, that medicines given by the mouth produce a greater 
degree of nausea than usually accompanies their exliibition, and very often 
actual and repeated vomiting. And, lastly, in many cases, whether the 
symptoms be well marked or obscure, additional value is given to them, — 
negatively by the absence of circumstances which indicate their dependence 
on some other kind of diseased action, and positively by the known tendency 
of the patient to hydrocephalus. 

In concluding this inquiry, I may be allowed to express a hope that no 
one will so far misapprehend the scope of my argument as to suppose that, 
irrespective of circumstances^ I would set down as being of the nature of 
hydrocephalus every case attended with * a pain in the head,' or even with 
more of the symptoms met with in cases of undoubted hydrocephalus, and 
subject it to the active treatment which that disease requires. But I sub- 
mit that this is not the error we are wont to commit, and that the caution 
we stand in need of lies all the other way. 

Aberdeen, Wth June 1844. 



Part IL— REVIEWS. 



Tfioughts on tJie Mental Functions; being an Attempt to treat Metaphysics as 
a Branch of the Physiology of the Nervous System, Part I. Edinbuigh. 
1843. 

To medical readers no apology can be necessary for indulging in a few re- 
flections suggested by a work on the mental functions. Not only do the 
mental functions belong most strictly to physiology ; but there is to be 
derived, from a practical acquaintance with the laws of mental operation, 
the greatest assistance in the daily practice of medicine, even when that is 
not particularly directed to mental diseases. And we have often regretted 
that books on this subject are so seldom presented to us otherwise than 
under so forbidding an aspect as to deter most men engaged in the active 
business of life from attempting to understand their obscurities. 

There are, however, one or two exceptions to this complaint. Dr Aber- 
crombie's work on the Intellectual Powers is one of the few which puts on 
an attractive form. And we can call to mind two other works which, 
though somewhat severe on the attention, are free from the overwhelming 
load of authorities and counter-authorities, disputations and counter-dispu- 
tations of established usage in such writings, we mean Dugald Stewart's 
Outlines of Moral Philosophy and Isaac Taylor's Elements of Thought. 

The work placed at the head of this article is not a popular exposition 



ON THE MENTAL FUNCTIONS. 263 

of the old metaphysics, but an attempt to direct the cultivation of that sub- 
ject into new channels. It is anonymous, which is rather a disadvantage 
to a book on a subject which requires not mere reading but laborious study 
before it can be pronounced upon. It is a small volume, of between 
two and three hundred pages, and is but a portion of the work, being 
entitled Part First. The titles of the chapters, eight in number, will show 
the topics of which the volume treats : — On the analysis of phenomena ; on 
mental analysis ; on association, with a note on secretion ; on sensation and 
volition, including the sensi-motor phenomena that constitute the optic . 
tangi-motor system, with a note on the cerebellum, spinal cord, and medulla 
oblongatii ; on hearing and the voice, including the sensi-motor phenomena 
that constitute the auditory vocal-motor system ; on sympathy and expres- 
sion ; on the faculty of enumeration ; and on the craniology of Dr Gall. 
There is, besides, an appendix on the physiology of the nervous system, a 
note on molecularity, an essay on the physical constitution of gaseous fluids, 
and a theory of heat. 

After this enumeration of our author's topics, what will most surprise 
our readei-s is, tliat it appears from several scattered expressions that he is 
not of the medical profession. Of his intimate acquaintance with the prin- 
ciples of certain parts of physiology a very cursory inspection of the volume 
is sufficient to convince us. Yet we dare not promise to subscribe to all the 
views he takes of physiological topics, and to all the uses he makes of them 
in his reasonings. Of one thing we are sure, he is a profound thinker, and 
as far as we have observed in the portion of his work hitherto published, 
for the most paii an exact and sound thinker ; and, though we fear we 
di£fer from him widely in many important views, we promise to ourselves 
much food for reflection by an occasional recurrence to his pages. 

Profound as the work undoubtedly is, it is not equally clear. We could 
almost suspect the author of being studiously obscure, did we not know 
how easy it is for one to fall into the error of regarding what is clear to 
himself as necessarily obvious to all the world. Moreover, we know that 
to obtain the pi-aise of clearness in writing we must confine ourselves to 
topics which are not obscure. This for the most part in metaphysics is 
impossible. It is not of ambiguity we complain — ^there is nothing of a 
choice between two interpretations ; it b of a total blank of meaning, till 
we have mastered the whole spirit of his discourse on the topic in hand. 

We proceed, then, to the particular examination of the work, while we 
apply to it, as we trust with due forbearance, those principles which we 
firmly believe to be the essence of metaphysical truth. 

The plan on which our author treats his subject we consider to be rather 
deductive than inductive ; that is, he does not attempt to reduce the ascer- 
tained mental phenomena to a small number of general laws, but assuming 
certain general facts in the physiology of the nervous system to be esta- 
blished, he endeavours to deduce from these the conditions under which 
mental phenomena take place. That this is the scope of the work may not 
at first sight appear to the reader, because, not to speak of the shadows 
thrown over the general plan by the numerous incidental illustrations from 
facts, analogies, and inferences in the progress of the work, he has nowhere 
collected into one view the principles from which he lias made his deduc- 
tions, but brings them out one by one no oflener than he has occasion to 
reason from each. 

The following few passages will indicate the turn of his speculations on 
the subject of scientific investigation in general, when oi*ganic nature is 



264 ON THE MENTAL FUNCTIONS. 

concerned : — " Analysis, in respect to phenomena, may be defined as the 
reduction of particular appearances into the more simple and general, and 
as classifying them according to their natural order of dependence or re- 
lation. If we seek to discover what are the essentials of all phenomena, 
we shall find that there can be no appearance, phenomena, or perception, 
without matter in a state of activity. Matter and motion may thus be 
viewed as the elements of which all things are composed ; and the dif- 
ference between phenomena, as limited to a modification of the properties 
of these elements. One phenomenon can differ from another only in so 
far as the essential properties of matter and motion admit of change in 
kind or degree." — Again, after some explanatory sentences, he says : — ^" The 
analysis of phenomena has therefore reached its extreme limit, when it 
has resolved them into specific variations, in kind and degree, of the 
essential distinguishing properties of matter and motion. The term 
analysis is therefore inapplicable to those essential properties. To extend 
causation to their existence is in fact absurd, yet it is an absurdity which is 
generally overlooked. Our sympathies extend to a final or first cause ; 
but the conviction of this existence which is implanted in the human 
mind — ^the most enlightened as well as the most illiterate — ^is due to feel- 
ing, not to strict causation." — Further on in the same chapter he says :— 
** The mental organism which analyzes, views every thing indiscriminately 
that presents itself to our senses or imagination as the acted upon ; the 
agent is thus for ever sought, and when found, is instantly viewed in its 
turn as the acted upon. The fiiculty seeks only to become acquainted with 
prior action ; not matter alone, but matter having velocity ; which is 
synonymous with motion, force, energy, and is implied in the use of the 
active verb. The abortive longing for the cause of abstract existence 
does not seem incongruous, nor does the possibility of the creation of 
matter out of nothing." Pp. 2, 3, 6, 7. 

In the notes on the physiology of the nervous system, our author has 
entered into particular details rather than marked out the great principles 
on which, as he says in his preface, his views are foimded : — ** The 
following attempt to study metaphysics as a branch of the physiology of 
the nervous system, is based on the great discoveries in this department 
of science that have distinguished the present age« The division of the 
nerves into motor and sensitive involves a principle that is all-important 
in tracing the primary relations of the mental phenomena. Combined 
with association, it seems capable of resolving Uiose difficulties in the 
doctrines of sensation which Dr Reid has so ably pointed out in his ** In- 
quiry," and which are certainly among the most formidable that beset the 
subject. The organology of Dr Gall is another splendid contribution to 
psychical science, the ofisprhig of the highest genius ; but, from being too 
hastily reduced to the popular standard, its value has been unfortunately 
obscured. The usefulness of phrenology in drawing attention to the de- 
pendence of the moral on the physical has perliaps more than compensated 
for its crudeness as a science." Preface. 

What we must regard, then, as the physiological principles on which this 
work, as a deductive inquiry, is founded, are such leading fiicts as the 
following : — That different nerves have originally distinct offices, as of 
conveying impressions from the peripheral pai-ts of the body to the nervous 
centre, and of transmitting motor influence from the nervous centre to the 
peripheral parts ; that the several component parts of the nervous centre 
are endowed with functions from the fii-st separate, and that those several 



ON THE MENTAL FUNCTIONS. 265 

component parts, or many of them, so communicate by nervous bands, that 
the impressions made on one part are capable of originating changes in 
the other connected parts, and fnee versa. Besides, it is manifest that his 
system rests on the belief that during every state of consciousness there 
most arise a change in some part of the material oi^anism. We nowhere 
find him directly affirming that such a change in the organism is all that 
constitutes a mental operation ; though his frequent use of the ambiguous 
phrase "mental organism," might lead the reader to suppose tliat his 
system is wholly a system of materialism. We object to the phrase 
mental organism as unscientiiie, and think that another expression which 
he uses^ namely, mental economy, should everywhere be substituted for it. 

Among our author's general principles we must refer also to the trans- 
mission to the ofilBpring of qualities acquired by the parent. Of this in 
the lower animals it is impossible to doubt, nor even in man, yet in his 
case within much narrower limits. The instances to which our author 
more particularly points are those recorded by Mr Knight as having been 
observed to occur in certain breeds of spaniels. 

These must suffice as specimens of our author^s general principles ; for 
we have not leisure to search for more of them in the scattered pages in 
which they may occur. But before entering on the consideration of the par- 
ticular deductions which he makes by the help of these and similar general 
principles, we must beg permission to state how far in our opinion it is legi- 
timate to rest a system of mental philosophy exclusively on such a basis. 

We believe with our author, not because it is proved directly, but because 
it rests on the strongest and closest analogies, that every act of consciousness, 
tliat is, every mental operation, is accompanied with a change in the 
material organism of the nervous system. In one sense, then, we agree 
with him that " one phenomenon can differ from another only in so far as 
the essential properties of matter and motion admit of change in kind or 
degree," But our author, we suppose, limits the term phenomena to ma- 
terial substance and motions observed ; but we use the term phenomena in 
a larger sense, and include under it states of action which are neither matttT 
nor motion — which are discovered without the assistance of the senses, being 
themselves states of consciousness^ — (the me) — and the discovering agent — 
(the I) — ^being also a state of consciousness. 

In ^ort, to say without limitation that matter and motion are the ele- 
ments out of which all things are composed, is a flagrant begging of a most 
momentous question, by which it is in e£Pect affirmed that mental operations 
are nothing but matter and motion. 

Our author, in reply, would perhaps suggest the last paragraph of his first 
chapter : ** It is to be feared, that if the mind is not fully impressed with the 
imperious necessity of applying this physical standard to all phenomena, 
whether moral or physical, — if the conviction is not matured and wholly 
derived from that experimental induction which has revealed the primary 
and most simple relations of matter and motion, — it is in vain to expect that 
philosophy will progress towards truth." 

We answer — ^by all means go on studying the machinery concerned in the 
mental operations ; but do not confound the mere machinery with the power 
—do not deceive yourself into the belief that you have discovered the mov- 
ing force whenever you have hit on some befoi*e unnoticed combination of 
wheels and levers. 

It is a striking fact in the history of man's waywardness, that no sooner 
is the long-chcrishcd delusion in mechanics — ^the foundation of the search 

2l 



266 ON THE MENTAL FUNCTIONS. 

after the perpetual motion — ^namely, the belief that machinery can generate 
power, banished from the popular mind, than straightway even men of 
science are found to take up the spirit of the same delusion in what concerns 
mind, and to insist on all followers of nature, on pain of being branded as 
behind the age, believing that no power is operative in the phenomena of 
mind, because some progress has been made in detecting the connexions be- 
tween the several parts of the machinery by which the effective power is 
applied. 

We know that the argument urged against this view is, that it is not in 
accordance with the rules of inductive science to receive anything as troth 
which does not rest on observation. But we are prepared to maintcon that, 
though the science of mind, when based upon reflection on the subjects 
of consciousness, may be technically excluded from inductive science, yet 
that it in no respect fails to answer to the spirit of inductive science, — ^which 
spirit is, to apply to subjects of research the mode of investigation suited to 
the nature of each, not in accordance with such fictitious rules of philosophy 
as kept men in darkness for ages, but in strict conformity to those precepts 
of common judgment by which a great part of our race has risen from 
a savage to a civilized state of existence. 

While, then, we admit in the fullest manner the study of the structure 
and functions of the nervous system, in so far as the observation of the at- 
tendant changes of matter and motion is concerned, to be of a high valae 
for the advancement of the science of mind, we must insist that there are 
other and higher modes by which it can be cultivated — modes which reach 
the actual phases of the mental power itself, and not the mei*e operations of 
the material machinery through which the power acts and is acted on. 

The faults committed in the cultivation of metaphysics on the old plan, 
are not proofs of the inadequacy of that plan under better regulation. We 
should expect much advancement from the cultivation of mental science on 
its old basis, but with such aids as the lights of modem physiology can 
supply. The science is still hung round with some scholastic lumber. 
We look upon debates as to the existence of an external world, and the 
evidence of personal identity, as little better than such questions, as " how 
many angels can dance on the point of a needle 1" or •* whether is an angle 
an affection of space or a property of matter !'* 

No man on this side of insanity ever really doubted of the existence of an 
external world or of his own personal identity ; and to attempt to prove 
what is intuitive or what became part and parcel of our nature at a period 
of in&ncy which memory cannot reach, is akin to nothing sd much 
as to the exploded delusion before referred to, which sought to create im- 
pulsive power by combinations of wheels and levers. 

The great defect of the old metaphysics is the neglect of the study of the 
varieties of individual intellectual character. In this respect phrenology 
has a manifest advantage. But in the phrenological collection of so-called 
factsy it is so difficult to separate the chaff fi-om the grain, that it is 
doubtful if any use can be made of them towards the improvement of 
metaphysics. 

The study of individual intellectual character implies, besides self-obser- 
vation, remark on mental operations in others ; and physiology already 
affords a basis for this kind of study in the variations of intellectual and 
moral character, observed from the earliest times in connexion with those 
slight structural differences of form with the predominance of certain func- 
tions, which are known as temperaments. 



ON THE MENTAL FUNCTIONS, 267 

If aay doubt should arise as to the practicability of ca]T>'ing the study 
of the varieties of intellectual character to such an extent as to be of use in 
the medical profession, we would refer to HoflFbauer s* work, of which Df 
Pritchard has made great use in his treatise on insanity, and in particular 
to his distinction between stupidity (dummheit) and silliness (bloddnn), 
both defective states of mind ; the first being attended with an unusual 
obstinacy, the other with an equally remarkable &cility of disposition. 

We cannot take time at present to illustrate this interesting topic ; but 
we have no doubt that it will be found, in many instances as well as in 
those just cited, that certain prominent qualities of mind necessarily imply 
other concomitant qualities^ and tliat the discovery of the presence of 
one may b$ made the means of inferring the presence of others, which 
is manifestly the same thii^ as obtaining the command of a general law* 
We have but space to add what we think an a fortion confirmation of our 
position, because it has reference merely to a command over one kind of 
muscular action. We refer to the undeniable dependence of the character 
of the handwriting on the temperament when that is at all well marked. 
And this dependence, we are very sure, is the foundation of the power 
which some practise, with no small success, of pronouncing on a person's 
character from his handwriting, though we believe that many have learned 
the secret empirically, without understanding the grounds on which their 
success rests. 

We would just hint at one or two other modes by which the science of 
mind might be augmented. Thus, what can be more instructive in this 
department than the consideration of the steps of self-education through 
which e^yety in&nt must pass, before the communication of knowledge 
through the medium of language begins ; or than the study of those steps 
by whieh the human faculties rise, as the objects on wliich they are exer- 
cised grow in extent and importance, while man advances from the 
humblest condition in which he is known on earth to such an intellectual 
superiority as Europe at present enjoys. In illustration of the advantage 
to be derived from the former method, we think we could show, did our 
limits permit, that the infant at the mother^s breast acquires the idea of an 
external world, not by such arguments as metaphysicians use, but by uni- 
formly discovering a double consciousness, or one in each of two parts, 
when his hand touches any part of his own body, while his consciousness is 
as uniformly single, when he touches his mother's breast, or any other 
external body. 

Besides these sources of improvement, we have no doubt that the know- 
ledge of the state of the psychological functions in the lower animals is 
destined to throw much light on the operations of the human mind. 

With these limitations on the exclusive plan which our author adopts 
for the cultivation of the science of mind, we proceed to notice sliortly 
Bome of his particular views. 

We take the following as the first specimen : — 

^ Impressions act upon the organisms of the propensities by means of and 
through the perceptive faculties. There must therefore be a class of con- 
ductora between the perceptive oigans and the propensities. The influence 
which they transmit is probably similar to that conveyed through the 
motor nerves; and if we carry out this comparison, each filament is 

* Hoffbaiier, Medecine Legale, &c», ou les lois appliquJes aux DJsordres de 
rintcUigence. Traduit par ChaiTibeyron. 



268 ON THE MENTAL FUNCTIONS, 

probably a conductor of tbis inilQence, and isolated from those adjacent. 
A very large proportion of the cerebral mass is probably composed of such 
conducting filaments." P. 27. 

Again : " Memory — the power which a mental oi^nism appears to have of 
retaining ideas corresponding to previous impressions from external objects. 
The idea beara no comparison with the impression in point of vivid dis- 
tinctness, yet it is the true representation of it in all its qnalities of form, 
magnitude, colour, &c. If it is the same organic substance that retains an 
impress of all those faint images with which the mind is stored, how is it 
that they are not confused by interference ! It is evident, from what has 
been suggested above, that the impression from without, assisted by a 
power from within, effects a cliange of some kind in the organic structure. 
• " The sexual passion is excited by the pei-sonal appearances of the opposite 
sex ; hence we may conclude, generally, that the change which takes place 
In the organic structure, corresponding to such impressions, influences 
personal demeanour and action, and irritates the elements of specific action. 
We may thus adopt, as an approximate deduction, that perception is 
a certain change in organic structure, accompanied with an irritative in- 
fluence over certain specific elements of action, and that these may exist 
either in a latent or active condition." P. 21. 

Again : <*The grand principles of association are nmuitaneouinesstaid Hmi- 
laritf/. The agitation caused by an idea or impression lasts for a perceptible in- 
stant ; and while another contiguous one is acting, the latter partof the first may 
be simultaneous with the first of the second. Similarity ought not per- 
haps to be reckoned an original quality of association ; because, when 
two impressions are similar, but not identical in all their parts, the com- 
parison and recognition of the similarity are distinguished by their respec- 
tive simultaneous parts being associated, and marking their difierence in 
all paHiculars. It does not require any specific principle of association to 
cause like impressions to excite like feelings or ideas. That the mind 
should inin from one train of thought to another, both having a eommon 
point of resemblance, is accounted for at once by the principle of simol- 
taneousness, if we reflect that the point of resemblance is actually an 
element of thought identical in both ; and when it is excited in the first 
train, the principle of simultaneousness is awakened in the second. It is 
therefore active in both, and will carry the mind in the direction where the 
ideas have been most vividly impressed." P. 24. 

Again : " The two prominent points of the mental economy thus appear to 
be, perceptive consciousness and directive effbrt. The passions, or organisms of 
the propensities, are the great sources of activity, which are acted upon by 
the former, and act upon the latter. 

** In motor association, the eflbrt is simultaneous with the degree and 
direction of the preceding muscular exertion. Is not a sirotlar conjunetion 
of phenomena necessary in all cases of association ! And may it not be de- 
fined, as the simultaneousness of an influence that proceeds from ^he seat 
of consciousness with another that arrives at it ! " P. 28. 

Our author's analysis of volition (chap, iv.) amounts to this — ^that ** two 
impressions must be engaged in the internal action — ^vix. 1st, of the part of the 
body to be moved ; and, 2d, that of the place to which it is to be moved. 
The action in the brain or nervous system to which the motion of the body 
conforms, is moving the first of these impressions to coincide with the latter.'* 
We cannot afford s])ace to follow him in the long inquiry next entered on 
to show the nature of what he tenns tangi-motor and optic-motor pfRfp- 



ON THE MENTAL FUNCTIONS. 269 

tions in reference to onr power of adapting muscular morements to the 
distance and direction of objects. His tang^-motor perceptions are the im- 
pressions of consciousness transmitted from the skin without the contact of 
external objects, and which carry along with them the sense of position 
(p. 66,) His optic-motor perceptions are tlie perceptions of the visual 
figure of the body, associated with these tangi-motor perceptions. On this 
point we are not more satisfied with our author's account than he is with 
that of Sir Charles Bell. We do not feel the difficulty here so strongly as 
our author, and that perhaps because we have been accustomed to consider 
the surface of the body, at all times afiPected by warmtli, tension, and other 
impressions^ as in an especial manner the seat of consciousness, owing to 
that great law of sensation by which the states of consciousness originating 
in the impressions made on the extremities of nerves are referred back to 
the points at which the impressions were made. It Is thus that the infant 
at the mother's breast acquires a knowledge of the form and dimensions of 
its body. The difficulty then, as it appears to us, does not lie in the attain- 
ment of a knowledge of the present attitude of the body, nor in the concep- 
tion of the attitude which is to be assumed, but in the explanation of the 
nature of that power by which man becomes able so to command his muscles 
as to change one attitude into an ever- varying succession of different attitudes. 
J'acility in this case belongs only to acts ccMnpounded of those to which he 
iias become accustomed. And the difficulty is not merely to discover what 
muscular volition is, but what is the nature of those almost painful effiorts 
by which one at length le^ms to write, to fence, to swim, to skate. We are 
inclined to believe that man has no power by volition over any muscle or 
set of muscles, till an impression, originating in the contraction of that 
muscle or set of muscles, has reached the nervous centre through the nerves, 
the contraction in this first instance being determined by such non-volun- 
tary forces as fall under the head of instinct or reflex action. Under this 
view, the power over the muscles of locomotion, and we may add of voice, 
originates in the same law by which the evacuation of the bladder and 
rectum, at first automatic, becomes voluntary. 

Our author continues the same subject in a note on the cerebellum, spinal 
cord, and medulla oblongata. ^* The remarkable experiments of M. 
Floorens have demonstrated, that the cerebellum is an oiganism interposed 
between volition and the corresponding motions of the body ; and it is 
generally believed to form the connexions necessary for executing combined 
movements. Do the preceding views throw any light on its functions ! or 
does the necessity of such an organiam tend to confirm the preceding hypo- 
theses^ and extend our acquaintance with the economy of the nervous sys- 
tem ! Does it organize that association between the tangi-motor and optic- 
motor systems which puts us at all times in liarmony with the position of 
external objects, and which has ever been so great a mystery in abstract 
physiology ! 

** The simplest effort of volition involves the active state of two impres- 
sions of which we are conscious ; but it manifestly involves the active state 
of a vast number of associated motor elements of which we are nai conscious* 
Is the cerebellum the mechanism that tmnslates the simple cerebral or eoii' 
acioiis phenomena of volition into the complex phenomena of muscular 
action, and that eliminatea, from the state of the sensitive nerves of the 
moflcles and of the skin, the optic perceptkm of position which is associated 
with the peripheral consciousness f Pp. 74, 76, 

The cerebellum af^^ean to be the depository of those impressions derived 



270 ON THE MENTAL FUNCTIONS. 

by the nervous centre from the muooles during their contiveUons^ the coB' 
tinued existence of whieb, whether as remembered sensations or states of 
consciousness, or in some less distinct fbrra, rudimentary of sensations^ in a 
rudimentary memory, appears to be essential to the continued voluntary 
power over the before-subjected parts of the muscular system. 

Our author enters into some very ingenious views on this subject. We 
thus interpret his meaning : When a movement is about to take place, there 
is a consciousness of the actual position of the body through the sensitive 
nerves of the skin, and what we shall call a conception of the intended new 
position (dependent according to him on the optic nerves), and these two 
states of consciousness belong to the cerebrum — ^to the cerebrum it also be- 
longs to will the change ; the impression made on the oiganism of the 
cerebrum by this act of will, must be conveyed to the cerebellum by com- 
municating nervous fibres; the cerebellum is the depository of those 
impressions made during the previous contractions of muscles of which 
there is no consciousness, but the continued existence of which is necessary 
for ihe repetition of such acts ; the impression made by the act of will on 
the cerebellum, through the communicating fibres, brings these stored-up 
impressions into activity in so far as required, and thus the fiat of the will 
is through motor nerves transformed into a change of attitude. This pro- 
cess is illustrated by a diagram/ 

The vocal-motor perceptions spoken of under the head of hearing and 
the voice, are quite analogous to the tangi-motor and optic-motor percep- 
tions before made use of. In short, we fear that our author has merely 
produced, in this consent between organs of sense and organs of motion, a 
kind of hybrid between the old idea of sympathy between nerves and the 
more correct modem idea, which makes sympathies to take place through 
the nervous centre. 

His chapter on sympathy and expression immediately follows. We 
extract the following passage : — 

** To analyze the sympathetic connexion which expression of counte- 
nance, tone, and gesture establish, it is necessary to examine minutely ev^y 
link of the chain of phenomena. First the mental excitement has a condi- 
tion of the brain to correspond with it. The brain is excited in a certain 
specific way. The respiratory facial nerve conveys the specific influence to 
the muscles pf the face, which thus experience certain specific contractions. 
Now, although we cannot always command our features, or banish from 
them the influence of the facial nerve, we are consdaus at ail times of the 
eatpresifion that they assume. This is a singular fact, which will stand ex- 
amination. The sensitive branches of the fifth cerebral nerve, distributed 
to the skin and muscles of the face, may be suflicient to convey an impres- 
sion of the state of tension and pressure that aflects it. But this is aooom- 
panied with a perception of the expression as it is pictured on the reitina of 
an observer; the same impress of expression, in short, is derived from 
common sensation, as by visual sensation when lookmg at the reflection of 
the face in a mirror." P. 118, 119. 

The next chapter is on the &culty of enumeration. The only difficulty, 
as it appears to us, which falls under the head of the faculty of enumera- 
tion, is the origin of that uncommon power pos8(.*ssed by some persons la 
ealculaticm. This we suppose our author is content to explain on phreno- 
logical grounds. We cannot admit the power of calculation to be of a 
character so special as to require an organ for itself. And we think the 
ordinary power of enumeration requires less explanation than almost aoy 



ON THE MENTAL FUNCTIONS. 271 

Other faculty with which man is gifted. It is one of the most elementary 
processes in the mental economy, and flows directly from the exercise of 
dmost erery fecnlty of the mind. We are inclined therefore to regard our 
author^s explanation as machinery which cumbers tlie subject. Colour, and 
the various modifications of sound, are special perceptions as compared with 
number. We can understand the necessity for special development for 
c^ial perceptions, and if the phrenological head were mapped out with the 
organs destined to special purposes only, we should be disposed to listen 
much more £sivourably to its pretensions. On this point of the want of 
specialness in the perception of number, we have one or two sentences to 
add as bearing on an important general view of the mental economy. On 
the simple power of recognising the diflfierences of numbers, and of adding and 
subtracting the same, depends the whole science of computation ; and these 
simple elements <^ arithmetic are of so universal a character, that the exor- 
cise of them enters into innumerable mental processes. To recognise unity 
is to have the power of reckoning numbers ; to discover that many of our 
sensations are not continuous, but interrupted by intervals, is to have com- 
puted ; to acknowledge resemblances and differences among our sensations, 
is to appreciate the difierences of number. No sooner was man able to 
perceive the resemblance between two fingers and two stars, than he had 
already apprehended the whole of the abstract idea of nimiber. 

It is on such grounds as these that we differ from our author, while we 
conclude that there cannot be any special organism for numbers, and that 
there is no need of any special theory to explain the operation of mind in 
regard to them. 

Our author's next chapter turns on the organology of Gall ; a subject, 
which for the present we are desirous to avoid. And with regard to his 
physical speculations, appended to the volume, w^e feel that such subjects 
are not fitted for our pages, even if we were inclined to enter on the discus- 
sion of them. We therefore take leave of our author w^ith the expression 
of our high respect for his talents, acuteness, and industry ; while we can 
truly say, that if our opposition to his views has grown more marked as we 
advanced in the examination of them, we have perceived at every step 
stronger and stronger proofs of the might of the adversary with whom we 
have entered on this, as we truly wish it to be, a friendly controversy. 



Facts and Observations on the Sanitary State of Glasgow during the last Year ; 
teith Statistical Tables of the late Epidemic^ showing the Connexion existing 
between Poverty y Disease^ and Crime. By Robert Perry, M.D., Pre- 
sident of the Faculty of Physicians and Surgeons, Senior Physician to 
the Glasgow Royal Infirmary, &c. 1844. 

Wb are sorry that circumstances prevented us from noticing the above little 
work of Dr Perry's in an earlier number, — a place which its merits cei'tainly 
deserved. It contains not only many important facts and observations of 
the author upon the sanitary state of Glasgow for the last year, but also a 
numbers of reports made by the various surgeons of the districts of that 
city. It is particularly valuable, as it was then that Glasgow was visited 
by that peculiar epidemic which attacked all the large towns of Scotland 
about the same time, and which was principally characterized by bilious 
vomiting, jaundiced appearance of the skin, rheumatic pains, and relapse. 



272 SANITARY STATE OF GLASGOW, 

Dr Perry gives a very good account of the various syniptoius, in nowise 
however differing from the descriptions previously given by others,* ex- 
cepting perhaps that he mentions observing a day or two before the i*elapse 
a strong craving for food. 

Our author considers it to have been an entirely different disease from 
typhus. ** The circumstance of this disease attacking those who had for- 
merly passed through eruptive typhus, and being followed by typhus when 
the patient was exposed to the infection of the latter, is sufficient to show 
that they are totally different diseases both in their character and causes ; 
as different as smallpox and scarlatina, or typhus and cholera." 

He likewise disbelieves that a similar epidemic prevailed in this country 
in 1818. ^ It has been stated that a fever of a similar cliaracter to tlie 
present prevailed in this country in the year 1818 ; I have been not an in- 
attentive observer for upwards of tliirty years, and have never witnessed a 
similar disease in this city." 

Speaking of its causes he observes : — ** In looking over these reports 
(district surgeons'), one striking feature in the circumstances of the thou- 
sands who have suffered most from the present epidemic presents itself; 
that is, the overcrowded state of their houses, families of six, eight, and ten 
individuals, crowded into one small apartment, without a bed to lie upon, 
if we except, perhaps, a quantity of long-used straw or filthy rags, emitting 
a stench of human impurity so offensive, that to one unaccustomed to it, is 
wholly insupportable, but to which the wretched inmates from habit ap- 
peared totally insensible ; those small apartments, being often let by the 
week, are filthy in the extreme." 

It prevailed to a great extent in Glasgow. " The number of cases," re- 
marks our author, "of the present epidemic, repoi-ted to the directors of the 
town's hospital, as attended by the district sui^eons during the last eight 
months, commencing May 1843, amounted in round numbers to 14,000, as 
seen by the table. Of those occurring in Calton, Bridgeton, and Andeiston 
districts, I have got no accurate return, but it is certainly within the mark 
to estimate it at 7000 ; those in the Gorbals and Tradeston districts at 2000 ; 
those treated in the Infirmary during the same period at 9000 ; those who 
were attended by private practitioners, not in the poor-roll, at 5500 ; and 
those treated in the Barony parish, in the suburbs, without the parliament- 
ary boundary, at £00 ; making a total of cases of epidemic fever in Gla^w 
and suburbs, during the last eight months, from the beginning of May till 
dOth December, 32,000, — exhibiting a fearful amount of poverty and disease, 
as it affected the poorest and most destitute of the population. Great as it 
is, however, I have been assured by the various practitioners who have at- 
tended the poor, that the estimate is far too low." 

The mortality which it occasioned was fortunately there as in other 
towns very low for the number attacked. " The returns from the Glasgow 
Royal Infirmary show a mortality from the fever of 5 per cent. The city 
district surgeons estimate theirs at 3 per cent. ; but from the table of the 
number of coffins given out by the town's hospital to the poor during the 
epidemic period, it is probable that there is some fallacy, as it is known all 
the poor on their roll do not apply for coffins, and that during the epidemic 
period there was a remarkable immunity from all other diseases. If we 
subtract 500 from 1846, it leaves S46, being more than the whole number 

* For accounts of the flymptonis of the late epidemic, see Scottish Medical 6a- 
aette, pp. 1, 129, 236, 321. 



ON PHYSICAL AND INTELLECTUAL LIFE. 273 

of coffins given out during the whole of the previous year, giving a propor- 
tion of mortality to the epidemic in the city of ahout 6 per cent, during the 
eight months of its prevalence ; hut taking the whole at 5 per cent., the 
mortality will amount to 1500 as the result of the present epidemic during 
a period of eight months." 

We cannot conclude this notice without saying how highly we estimate 
local reports of this kind, especially when executed with that care and in- 
dustry which Dr Perry has bestowed upon his " Facts and Observations." 
Wc shall at all times be happy to give publicity to such in our pages. 

The work is printed by patients at the Royal Lunatic Asylum, Glasgow, 
which accounts for some inaccuracies that cannot escape attention. It con- 
tains, however, a well-executed map of Glasgow, with the different districts 
more or less deeply coloured as the epidemic more or less prevailed in them. 



Lecture on PhyHcal and Intellectual Life. Delivered before the Educational 
Society of 8t Mary's^ Birmingham. By Samuel Wright, M. D., &c. 
London, 8vo, pp. 68. 

Dr Wright is very favourably known to the profession by several valu- 
able and interesting contributions to medicine. His papers on the Ergot of 
Rye, his Thesis on the Physiological Action of Mercury and its Chlorides, 
his Researches into the Pathology of the Salivary Secretions, and other 
interesting memoirs, have established his reputation as a most intelligent, 
industrious, and successful cultivator of medical science. 

This lecture, as designed for a popular audience, brings him before us in 
another aspect, as the eloquent advocate of certain great general principles 
in physical and psychological science. The object for which it was 
designed has lAduced the author to deviate from that close and precise line 
of reasoning which the subject would in other circumstances require, and 
to render' hb style more elevated, both in the way of general reflections 
and language, than would other^'ise have been suited to a metaphysical 
and physiological disquisition. Although rather florid to our taste, we 
have been highly pleased with the general bearing of the lecture. With 
the doctrines regarding materialism and imniaterialism, vitality and spiri- 
tuality, laid down by the author, we in many respects concur, and deem 
such a popular exposition of those doctrines to be of much practical utility. 
They are illustrated by many pleasing and interesting examples derived 
from poetry, and natural phenomena, cliemical and vital. 

The author has adopted the views advocated by Dr Pritchard in his 
work on the vital prmciple. He argues with the materialists, that life is 
the result of organization, a property of oi*ganized matter, and with the 
immaterialists, that thought is a property of an unknown principle, super- 
added to oiganized matter, which we call mindy spirit, or souly an immortal 
and imnoaterial entity. 

In regarding this entity, however, as the distinguishing feature between 
man and brutes, we conceive that he strikes at the root of the arguments upon 
which it is contended that thought cannot be a property of matter ; — ^for 
who can deny to the lower animals the possession of those qualities which 
distinguish mind ! 

The whole ailment may be comprised in a few words. All the 
phenomena of matter, organic and inoiganic, may be referred to a few 

2 u 



274 ON DYSMENORRHOSA. 

general properties common to all matter. Even vital phenomena, he argues, are 
not different in kindy but only in modification, from the general properties of 
matter. The phenomena of mind, on the other hand, even in its simplest 
manifestations, are entirely diflferent in kind from any of the known 
properties of matter, and cannot therefore be referred to the same cause. 
While the one set of properties, therefore, are ascribed to a certain un- 
known cause called matter^ the other must, on the same principle, be re- 
ferred to a different ens, which we call mind. 

If this argument should appear to confer immortality on brutes as well 
as on man, tlie fault is with those who base the doctrine of the soul's im- 
mortality upon the proof of its immateriality, and not upon evidence of a 
much higher kind. It would be wrong, however, to judge hypercriticaily 
on a part of the subject which probably did not come within the design 
and scope of the author in the composition of a lecture for a popular 
audience. 

As a whole, the lecture is alike creditable to the erudition and scientific 
attainments, to the head and heart, of the author. 



On Dysmenorrhcea and other Uterine Affi ctions in Connexion with Derange- 
ment of the Assimilating Functions, By Edward Rigby, M.D., Lecturer 
on Midwifery, &c. 12mo, pp. 138. London, 1844. 

The volume before us is divided into two parts, — ^the first embraces the 
influence of assimilation on the circulating system ; and tlie second is de- 
voted to the effects of mal-assimilation on certain uterine derangements. 
In his preface the author very modestly states that he hesitates to submit 
his observations to the profession, as his investigations have not been so 
perfect as he could wish. But notwithstanding this deficiency, as Dr Rigby 
informs us that he not only enjoys an extensive field for his inquiries, but 
that since 1831 he has devoted his attention to the subject under considera- 
tion, we have more than ordinary encouragement for noticing his exertions. 
We regret, notwithstanding our favourable anticipations, to be obliged, 
in the very commencement of our strictures, io differ in opinion from the 
author, who states (preface, p. 1), that "these affections on the whole 
excite less interest among the generality of the profession than any other 
class of diseases." With the sentiments of the generality of our brethren 
south of the boundary we cannot pretend to be acquainted ; but some of 
them, we can state with confidence, do not participate any more than we 
do ourselves in the foregoing sentiments. We can well remember, that 
from the time we could pretend even to a very moderate share of practical 
knowledge of female diseases, individuals affected with dysmenorrhoea, more 
especially matrons, excited considerable solicitude, from this derangement 
being not only very difficult of removal, but being also almost invariably 
accompanied by sterility. Of this latter fact even females themselves are 
not ignorant ; for we presume that other members of the profession as well 
as ourselves have been consulted by mothers as to the propriety of young 
females contracting a matrimonial alliance while suffering fVom this variety 
of menstrual derangement. Moreover, if dysmenorrhoea has not sufficiently 
commanded the attention of some of our brethren, this must be ascribed to 
their having been but indifferently gifted with the power of observation, 
since it may unquestionably be followed by very distressing results. We have 



ON DYSMENORRHOSA. 275 

long been of opinion — and our sentiments have been satisfactorily corrobo- 
rated by Dr Lever in his excellent work on Organic Diseases of the Uterus, 
noticed in the first number of tins Journal — ^that females who have been 
martyrs to painful menstruation are very liable, at an advanced period of 
life, to be the subjects of cancer uteri, — a fact which is nowhere noticed by 
the author of the work under review. 

The first thirty-five pages of this work are occupied with a repetition of 
Dr Front's sentiments regarding the influence of mal-^ussimilation. To enter 
on an analyds of these speculations would be inexpedient, since they have 
been for some time before the profession, and must be familiar to most of 
our readers. We shall merely content ourselves by making some observa- 
tions on the causes of chlorosis and dysmenorrhcea, the most obstinate of 
the affections treated of by our author, who has not at all acquitted himself 
on this head so well as we were led to expect, considering the advantages 
he has enjoyed. If mal-assimilation from defective and improper nourish- 
ment were influential in producing these diseases, they ought to be very 
prevalent among the humbler classes, who are most exposed to such causes ; 
but that the reverse is the case, considering their numerical superiority, 
must be well known to all practical men. The circumstances most condu- 
cive to the aflections refciTed to are originally feeble corporeal stamina, a 
strumous diathesis, long continued mental distress, a sedentary occupation, 
breathing an impure atmosphere, and a laborious employment ; and when 
combined with these, it is not improbable that the causes above noticed 
may exert considerable influence. What possible analogy Dr Rigby can 
find between dysmenorrhcea, gout, and rheumatism we are at a loss to dis- 
cover, except that they are all attended with pain ; and upon the same 
principle we may erelong expect to be informed that dysmenorrhcea is allied 
to colic, tootliache, and earache. 

The next forty-five pages are devoted to the symptoms and treatment of 
dysmenorrhcea chiefly ; and, giving the author all due credit for his industry, 
we cannot help observing that there are some obvious contradictions in this 
portion of the work, and that the symptoms have, in some respects, been 
liar too minutely described. For example, at p. 37, we are informed that 
there is heat, swelling, redness, and pain ; and at p. 48, that not unfrequently 
tlie canal is so exquisitely sensitive as to render the introduction of the finger 
very painful and sometimes even impossible. Again, at page 61, we are told 
that " the passage is too irritable and swollen to bear the introduction of an 
instrument." It has never fallen to our own lot to meet with cases attended 
with symptoms so violent ; and we are naturally led to ask the author how 
he can undertake to speak so confidently regarding the condition of the 
sexual canal, when neither a finger nor an instrument could be introduced 
for the purpose of exploration ! 

As specimens of over minuteness in describing symptoms, we may notice 
the following : '^ There is a bilious headache across the forehead (p. 41) ; the 
labia and nymphs are usually found swollen and flabby, and copiously 
moistened with a thick, creamy, albuminous discharge (p. 42) ; it is every- 
where covered with the above-mentioned white or yellowish- white dis- 
charge (p. 43) ; the fecal mass is ensheathed by the mucous secretion, and 
although formed, and even solid, glides from the intestine with that degree 
€Kf ease," &c. ; and again, " a secretion of gas takes place in the vagina, and 
also in the rectum." Our readers will, like ourselves, be naturally curious 
to know what description of ladies could be so communicative to Dr Rigby. 
Such minute details might have been expected of a physician writing in 



276 ON DYSMENORRH(EA. 

those times when our hrethren were required not only to examine hat even 
taste the urine and fieces of their patients ; hut in the present day we are 
sure no writer would incur the censure of a reviewer for dispensing with 
them. 

The treatment pursued in the suhjects embraced in this puhlication is, to 
say the least, judicious ; hut, in passing, we cannot avoid noticing a novel 
mode of using one of the preparations of opium recommended at p. 61, viz. 
*^ to apply to the vagina, hy a camel's hair pencil, some almond oil with a 
little extract of poppy or liq. opii sedat. That in, the present day the fe- 
male organs are examined with a degree of freedom which, thirty years ago 
even, would not liave been tolerated by the sex, and remedial measures adopted 
which it would have been hazardous in the extreme to propose to them, we 
are ready to admit ; but we must reprobate such conduct in the strongest 
terms when the relief of ihe patient can otherwise be as efficiently accom- 
plished. 

The remainder of the worlc embraces some cases in illustration, and the 
modes of analyzing the urine, which, though as we believe founded on sound 
information, we shall leave our readers to consult for themselves, as we have 
already extended our observations beyond the limits usually appropriated to 
works of this magnitude. 



Part III.— PERISCOPE. 



ANATOMY AND PHYSIOLOGY. 

Doubts as to KiemarCs Views of the Structure of the Liver, 

Kierkan's observations upon the structure of the liver, and the relative 
positions of the component tissues of that oigan, have been very generally 
believed by anatomists and physiologists of the highest authority to be 
correct. 

Kieman considers, as is now almost universally known, that he had 
from direct observation proved that the capillaries of the vena porta: com- 
municate with the radicles of the hepatic veins ; the latter being situated 
in the centre (the intralobular veins) of the acini or lobules of the liver ; 
the former ramifying between and upon the surface of these bodies — the 
interlobular and lobular veins — and that the liepatic artery is the vessel 
that furnishes the supply of nutritious matter for the nourishment of the 
biliary canals, the arteries, veins, and the envelopes which isolate the 
acini from each other. 

These statements are to a certain extent opposed to a series of observa- 
tions contained in the fourth number of Muller's Archives for 18i3, made 
by MM. Weber, Krukenberg, and Miiller. 

The objects which MM. Weber and Krukenberg have in view are to 
demonstrate the existence of vascular capillary reticulations, which are the 
last ramifications of the vena porta, and the radicles of the hepatic veins ; 
the meshes of which are occupied by the biliary canals, which, like theia, 
also forms a complete network. These writers state, moreover, that the 
hepatic artery communicates directly either with the vtna porUe or the 
capillary network, thus differing in reference to this latter point completely 
from the views entertained by Kiernan. 



THE STRUCTURE OF THE LIVER. 277 

MM. Weber and Krukenbeig denj the existence of acini. They be- 
lieve that the liver consists of a continuous mass, in which the vessels and 
ductsy situated in distinct channels, are placed. 

The smallest ramifications of the hepatic vein are distributed between 
those of the vena portcB, but at a sensible distance from each other ; the 
space between them being filled up by cellular tissue, and by the com- 
mencement of the hepatic ducts. 

M. MuUer, however, supports the old opinion of the division of the liver 
into lobules or acini ; and states, that if Weber and Krukenberg have not 
been able to see the cellular and fibrous tissues which envelop these, it is be- 
cause the injection used has so distended the vessels as to obliterate by 
pressure the interlobular spaces. Miiller states, that to exhibit the acini 
distinctly, it is merely required to macerate the liver in acetic acid for eight 
days or so. By this process the cellular tissue is destroyed, the lobules 
remaining suspended by the radicles of the hepatic veins. The terminations 
of the biliary ducts have not yet been observed by Miiller, although this 
excellent observer has looked for them with the greatest possible assiduity 
and care. MM. Weber and Krukenberg state that they have succeeded 
in demonstrating the existence of a plexiform network formed by terminat- 
ing branches of the biliary ducts, in the meshes of which the vascular 
capillaries are placed. — From MiilleT^s Archives^ No. iv. 1843. 



SURGERY. 
On Ea^cision of the Head of the Femur. By Dr Ed. Bonino. 

In the April number of the Annales de la Chirurgie there is a memoir on 
this operation by M. Bonino, and in the same journal for May he has pub- 
lished the history of two additional cases, the account of which he had 
received subsequently to the publication of his first paper. The cases 
which he has collected amount to twelve in all, and we shall append an 
abstract of them, as, with the exception of two of them, they are but little 
known in this country. 

The first case which he relates is the one by Mr Whyte of the West- 
minster Hospital, who we believe was the first who actually performed 
this operation. On the Continent, surgeons appear to doubt that he actu- 
ally performed the operation, believing that he limited himself to its pro- 
posal. That he did so, however, and with suc-cess, is well known in this 
country, as the case was published in the London Medical Grazette in 1832, 
and the parts removed are still preserved in one of the London museums. 
We find, likewise, that the case is alluded to with approbation by his 
colleague Mr Guthrie, in his clinical lecture, in the following terms : — 
*^ Mr Whyte, my colleague in this hospital, removed the head and neck of 
the thigh bone in a young person, by a very simple operation, after it had 
been dislocated by the same disease, ulceration of the cartilages and head 
of the bone, because it was evidently causing great irritation. The patient 
was a boy aged fourteen years, and recovered, with a useful articulation, 
and without the limb being much shortened." 

The second case which he gives is published in the Gazette Medicak for 
1885, and occurred in the last expedition of the Russians against tlie 
Turks in 1829. The operation was performed by M. Oppenheim. The 
patient had been wounded by a ball in the left coxo-femoral articulation. 
On enlaiging the wound, M. 0. found that a comminuted fracture of the 



278 ON EXCISION OF THE HEAD OF THE FEMUR. 

head of the hone existed, and that a portion of the upper border of tlie 
cotyloid cavity had been detached. He removed the injured parts with 
some difficulty, and the case held out very fair prospects of success until 
the seventeenth day, when the man was much alarmed by the occurrence 
of a case of plague in the ward, and the same evening intense fever super- 
vened, and he died next day. 

The thu'd case in which the operation was performed was by M. Sentin, 
at the siege of Antwerp in 1832, likewise for fracture by gun-shot wound 
of the head of the femur and trochanter major. For a few days the man 
did pretty well, but gangrene of the limb supervened, and he died on the 
ninth day. 

The fourth case was by M. Schmalz, in Saxony, for caries of the head of 
the bone, which was already detached from the shaft. The boy was cured 
after a lapse of three years, and a new joint was formed by the trochauter 
major. 

In the fifth case, the operation was performed by Mr Hewson of Dublin 
for caries. The bone was divided above the trochanter minor, but the 
patient died three months aftenvards from abscess in the pelvis, connected 
with disease of the cotyloid cavity. 

The sixth case given was by Schlichting, in 1829. Tlie patient was a 
young girl st. fifteen, and was cured in six weeks, being able to walk 
easily with a little halt. 

The seventh case was by Kohleren Heine of Wurtzburg, and was like- 
wise successful. The eighth case was by Kluge, and likewise for caries, 
but the patient died on the second day. 

The ninth case was by Vogel, in a young girl affected with morbus 
coxarius, and was successful. 

The tenth case was by MM. Jaeger and Textor, in a child of seven and 
a-half years, with fracture of the neck of the femur and abscess. It was 
unsuccessful, the patient dying on the twenty- third day. 

The eleventh and twelfth cases were both by Textor, for disease of the 
upper part of the bone, but both were unsuccessful, the first dying the day 
after the operation, and the second on the fifty- third day. 

In the remarks with which M. Bonino follows up the enumeration of 
these cases, he advocates strongly the propriety of the operation under 
certain circumstances, contrasting it with amputation of the extremity, the 
operation hitherto recommended, and giving it a decided preference, as we 
agree with him it ought to have. 

We have here, in the twelve cases, five which succeeded perfectly, a 
favourable result which the most strenuous advocate for amputation could 
never look for ; and if we were to put out of the. question those cases in 
which the operation ought never to have been performed, and of these 
there are several, this practice would of course contrast still more favour- 
ably with the other. When we consider, in addition, the fact that the 
limb in all the cases has been left in a state well adapted for all the 
ordinary purposes of progression, &c., we conceive tliat the two operations 
will scarcely bear comparison. 

We find that our latest writers on military surgeiy speak highly in 
favour of the operation. Mr Guthrie, in his clinical lectures, speaks thus : 
** I liavc not done this operation on a living man, but you must do ity and I 
am sure that in the end you will succeed. You ought not to be allowed 
to take out a limb at the top joint, unless the head and neck of the thigh 
bone are injured ;. and you ought not to take it out if they ane, unless the 



ON EXCISION OF THE HEAD OF THE FEMUR. 279 

shaft of the thigh hone is irreparahl}- injured also.*' Sir G. Ballingally in 
his Outlines of Military Surgery, says, " The hazardous character of wounds 
inTolving the hip-joint is well known to every experienced surgeon, and the 
removal of the thigh at the hip-joint, recommended for some of these wounds, 
is an operation which no one can contemplate with any sanguine hopes of 
success. The experience of the excision of the head of the femur in cases 
of caries is not extensive, hut it appears to me to he encouraging ; and since 
I have become familiar with the excision of other joints, I have frequently 
reflected upon the possibility of substituting the operation of excision for 
that of amputation at the hip-joint, in some of tliose cases of gun-shot 
wounds where the latter has been recommended. And I am now encour- 
aged to speak with more confidence on this point from finding the operation 
advocated by one of the first authorities in military surgery, Mr Guthrie, 
in his clinical lectures recently published." M. Bonino does not deny the 
fact that the operation is a very serious one ; on the contrary, he admita 
that it is ; but he very justly remarks that this is by no means a sufficient 
reason for rejecting it altogether. Serious operations are always authorized 
by the circumstances which demand them — ^they are only legitimately per- 
formed, in fact, in diseases which if left to nature inevitably lead to a fatal 
result. The severity of the operation is then, if we may so speak, propor- 
tioned to the serious nature of the affection which demands it. 

In all these cases, then, in which any hope of recovery by surgical inter- 
ference is oflRered, the surgeon has only the alternative of choosing between 
excision of the head of the bone and amputation at the articulation. The 
question then is not whether excision be a severe operation — this no one 
doubts — ^but whether it be less severe than amputation. 

M. Bonino then proceeds to draw a comparison in detail between the two 
operations. We shall not follow him through that part of his paper ; the 
result of his comparison we have already given. 

The cases in which he recommends the section of the head of the bone are 
the following : 

1*/, Dislocation, with protrusion of the head of the bone through the soft 
parts^ which it is found impossible to reduce, 

2rf, In gun-shot wounds involving the upper part of the bone. 

Sdy In caries of the upper part of the femur, whether primary or 
secondary. 

In regard to the two first, the opinion of the profession appears to be 
very much at one, but in regard to the last there is still, and very naturally, 
much difference of opinion. 

The great objection to interfering in cases of caries consists in the fact 
that the cotyloid cavity is very generally involved m the disease, and 
likewise in the difficulty, we might almost say impossibility, of saying 
when it is not. Any operation undertaken when this part is affected is 
woiTse than useless, as we only remove part of the disease, leaving behind, 
perhaps, the portion most likely to lead to a fatal result. Such indeed 
appears to have been the cause of death in some of those operated on. 

M. Bonino appears to agree with those authors who believe that the 
head of the bone is first affected, and the cavity secondarily, and argues 
that if the affection of this part be not extensive, and being as it were the 
effect of the caries of the head of the bone, we might hope, having 
removed the cause, to see the diseased action in this part checked at its 
commencement. We cannot agree with M. B. in this, and are of opinion 
that if there be evidence of the cotyloid cavity being affected, that 



280 CASE OF TETANUS. 

surgeon will best consult his own reputation and the good of his patient 
who declines interfering. We cannot conceive that the cautery, as recom- 
mended in such cases by Briat, or the gouge and mallet, by Moreau, would 
be of much avail. We ought in justice, however, to add, that in two of 
the cases related, the cotyloid cavity was unaffected, and that amongst the 
five successful cases, thive were perfonned for caries involving the articu- 
lation. 



Ca9e of Tetanu9 foUowing the Medtanical Cure of a Fistula Ladirymalu, 
By M. Petbi. 

Case. — ^A woman, aged fifty, of a lymphatic temperament, subject for a 
length of time to a rheumatic afiection, wished to get rid of an epiphora 
which annoyed her. In consequence, a surgeon Incised the diseased parts, 
introduced a seton (meche), and after a time the nail-headed style of 
Scarpa. During all the operation, the patient coropliuned of a pain which 
extended &om the artificial canal to the eye, to the cheek, to the forehead, 
and to the angle of the jaw. E^ht days had elapaed, when, after a sleep- 
less night, the patient found that she could no loi^r open the mouth. In 
the evening, M. Petri found a contraction of the masseter and temporal 
muscles, as well as general convulsive movements. He proposed to remove 
the style from the lachrymal sac ; but the ordinary medical attendant^ who 
did not see in these symptoms any thing but a rheumatic afieeUcm, would 
not consent. The treatment^ therefore, was limited to a blood.letting and 
to twenty leeches applied to the neck. The following day, the rigidity 
had extended to the muscles of the neck and of the trunk ; those of the 
arms became afiected In their turn ; lastly, the convulsions became general. 
The style was then withdrawn, and opium was administered ; but, not- 
withstanding a deceitful remission, the patient sunk at the commencement 
of the fourth day« — Sectio. The lachrymal passages did not present any 
extraordinary injury. The rest of the body could not be examined. 

Dr Betti, to whom M. Petri related this case, told him that formerly he 
liad seen a patient seised with trismus at the moment when Yacci intro- 
duced a seton (meche) into the nasal canal. That celebrated suigeou, 
suspecting the cause of this accident, immediately removed the foreigu 
body. The trismus subsided in a short time ; and afterwards there was 
no more thought of curing the patient of the fistula lachrymals. — ^From the 
Gazzetia Totcana deik Scwnsee MediahFinchey in the Gazette MSdicak, 
18 May 1844. 



Wound of the Beart apparently Cured. By M. Mabiki. 

Case. — ^The patient, Angela CeccareUi, aged thirty-two^ received, on the 
11th July 1848, a blow with a knife in the region of the heart She fell 
in a fiunty losing a considerable quantity of blood. M. MAwni^ who was 
called in immediately, found her fidlen into a profound sinking, covered 
with a cold sweat, witii di£Bcult respiration, repeated syncopes, and a flut- 
tering and unsteady pulse* The wound was situated on the inner side 
of the breast, at two inches and some lines from the sternum. On con- 
sidering its direction, it was found that it penetrated between the fourth 
and the fifth rib. Judging from these signs, M. Marini concluded that the 
patient was in danger of death, it being very probable that there was a 
wound of the pericardium. She was carried to the hospital, and finding 



WOUND OF THE HEART APPARENTLY CURED. 281 

herself a little better on the foUowing day, she was examined by another 
medical man, who declared that the wound was a simple penetrating one, 
and would hardly lead to filial eenseqnences. The patient not having been 
confided to the care of tile author, he only knew that six or seven blood- 
lettings and repeated iqiplications of leeches were had recourse to, and that 
on several occasions she was in imminent danger of death. However, the 
external wound cicatrized, and the patient was dismissed firom the hospital 
on the 26ih August, declared perfedly cured. She was seen for some time 
after going about the streets, presenting the signs and marks of wasting 
away. At last, on the 16th September, having got up very early to satisfy 
a call, she fell suddenly, and died in a few minutes. 

Sectio, — The external cicatrice was solid and complete. The reuniting 
tiaaae which followed it could be easily traced between the fourth and fifth 
ribs to the interior of the chest. The sternum being elevated, there escaped 
from the left tlioracic cavity half a pound of inodorous lymph of a clear 
yellow colour. A point of the pericardium presented an abnormal thick- 
ening, as well as traces of an inflammation not altogether subsided. There 
existed numerous and solid adherences of the summit of the left lung. A 
cyst of a bluisli-black colour, filled with coagulated and fluid blood, ad- 
hered by a large pedicule to the left side of the pericardium. The pericar- 
dium being raised up and opened, it was found filled with clotted and fluid 
blood, the quantity of which was estimated at about two pounds. The 
heart was atrophied, thinned, and fall of blood. It was penetrated near its 
point by a round and conical hole, which, like a sphincter, communicated 
with the left ventricle. This opening, sufficiently large to admit easily an 
ordinary pair of forceps, presented at its circumference a sort of whitish 
callosity, soft and smooth, which corresponded exactly to the above- 
mentioned cicatrice of the pericardiam. — From the // Raccoglitore Medico^ 
and given in the Gaxette MSdicaley 11 Mai 1844. 



MATERIA MEDICA AND DIETETICS. 

Valerianate of Zinc in Neuralgias and in Chronic Satyriasis, 

The valerianate of zinc was suggested for use as an antispasmodic by 
Prince Louis Lucien Bonaparte about a year ago, and has since been much 
commended chiefly in the Italian journals of medicine. In the last number 
of the «• Gazette Medicale de Paris" for June of this year, Dr Fiancis 
Devay of the Hotel Dieu of Lyons has published an interesting memoir on 
this new medicine. Dr Devay does not find the physiological action of this 
drug to be greater than that of valerian or of zinc separately, but he regards 
its medical efiects in certain diseases, as in epileptic maladies and nervous 
afi^ectionsyss prombing to be of the greatest service. He abstains from pub- 
lishing any account of its good effects in the more serious forms of disease, 
till a longer time has tested their permanence. But in this memoir he 
reports four cases of neuralgia and one case of chronic satyriasis, which, 
after resisting the oi-dinary ti-eatment, were completely cured by this re- 
medy. The following is his prescription : — 

R Valerian, zinc. . . gr. x. (6 decigr.) 

Gummi tragancanth. . . 388. (2 gram.) 

Ft. pill. xii. Sumat. unam mane et vespere. 

As want of room prevents us from giving any further account of this 

memoir, we probably shall recur to it in a future number. 

2 N 



282 ON THE TREATMENT OF SYPHILIS. 



PATHOLOGY AND PRACTICE OF MEDICINE. 

"We this month lay hefore our readers an abstract of a paper by Dr 
Hocken, " On the Comparative Value of the Preparations of Mercury and 
Iodine in the Treatment of Syphilis," which appears in the April number 
of the Edinburgh Medical Journal. 

Recent changes in our opinions respecting syphilis have teiided much 
to perplex pi-actitioners as to the proper method of treatment ; the opposing 
parties have probably each been too exclusive ;' and we regard the paper of 
Dr Hocken, though containing nothing original, as valuable from its con- 
densing the opinions of the most trustworthy writers on the disease. We 
shall take the liberty, however, of still farther compressing it. 

On the Treatment of Syphilis by Mercury and Iodine, ' 

1. Syphilis can be cured without mercury. — 2. This does not prove that 
the non-mercurial treatment is the most advantageous. — 3. The main points 
are to know where to employ mercury and iodine, and when to refrain from 
their employment. This is discussed under three heads. 

1*^, /* the plan of treatment by mercury and iodine superior to any other ^ 
—The use of mercury was formerly carried to an unwarrantable length. 
Excessive use of mercury by no means a preventive of secondary symptoms. 
In Sweden, prior to 1814, mercury largely used in primary syphilis; 
average number of secondary afiFections of bones, M per cent. After 1814, 
use of mcrcui-y more limited ; number of diseased bones reduced to 6^ per 
cent. 

Two kinds of chancres, indurated and non-indurated ; former heal much 
more rapidly with mercury. Sore not cured properly if hardness remain. 
Many sores which appear to heal rapidly under simple treatment leave 
behind indurations. Evidence of medical officers during last peninsular 
war shows, that all sores are curable without mercury; proportion of 
secondary symptoms where mercury used, 1 in 7o, where none exhibited, 
1 in 10 ; that all the secondary forms of syphilis may be cured without 
mercury ; tliat secondary symptoms under such circumstances are unusu- 
ally mild ; that unless when indurated, primary sores healed as rapidly 
without as with mereury. But all admit that there are some sores which 
can be healed in a few weeks with mercury, which would require as many 
months without it. 

With regard to iodine, Dr Wallace states, that it is heroic precisely in 
those forms to which mercury is least suited. Ricord states, that where 
mercury ceases to be useful, the hydriodate of potass proves the most 
valuable and efficacious remedy ; but there are mixed cases of secondary 
and tertiary symptoms where a combination of the two is required. 

2rf, Comparative value of mercury and iodine in the treatment of the dif- 
ferent farms and stages of syphilis,'-^As a general feet it may be stated, that 
a modified mercurial treatment is applicable to the primary and secondary 
foima, while the hydriodate of potass exerts the most undoubted effiict in 
the tertiary. 

According to Ricord, the characters which chancre display do not depend 
on the specific cause which produced them, but on constHutional peculiar- 
ities, mode of Uving, and the local treatment of the sore. In all simple 
iraneties of chancre, as soon as they have assumed a quiet condition under 
antiphlogisUc regimen (if they do not heal quickly without ferther assist- 



ON THE TREATMENT OF SYPHILIS. 283 

ance)y we should liave recourse to a mild mercurial course, and to its local 
application^ not so much to^promote as to hasten cicatrization^ and to pro^ 
tect the constitution. 

The danger of secondary symptoms is in direct ratio to the duration of 
the primary ones, so that that mode of treatment should be adopted by which 
they are found to be most speedily cured. In the first stage we have to do 
with a specific sore, both irritable and poisoned, as well as itself poisonous^- 
readily ulcerated by remedies ; while in the second we hayc a simple ulcer 
destitute of all these traits. If mercury, short of salivation, fails to produce 
a cure, it should not be persevered in ; but hyd. of potass with sarsaparilla 
be given instead, though it seems to exert but little influence over them. 

Indurated Chancre. — ^The advantages of a full mercurial course in this 
form is clearly proved by the united testimony of all the best modem 
authorities. It should be continued until the sore is healed, and alt indura- 
tion of the cicatrice has disappeared. This does not apply to those cases 
where the induration has been produced by improper applications (which 
are to be distinguished by the inflamed as contrasted with the livid or 
white areola), unless the induration persist after antiphlogistic treatment 
has been employed, and the inflammation has yielded. 

Phagedenic Chancre. — Most authors concur in thinking that as a general 
rale mercury should .not be used in this variety, though occasionally it is a 
valuable remedy. Dr Wallace, by whom Dr Hocken is chiefly guided, 
divides these cases into nine varieties — a division which he regards as prac- 
tical, and on which he founds his rules of treatment. 

WiUioui Stoagh. With White Slough. With Black Slough. 

1. Simple. 4. Simple. 7. Simple. 

2. Inflamed. 5. Inflamed. 8. Inflamed. 

3. Irritable. 6. Irritable. 9. Irritable. 

In the 1st variety, mercury — ^unless it has been previously employed — 
in that case mineral acids with sarsaparilla, and topical mercurial applica- 
tions with fumigations. In 2d variety mercury should not be given till 
chancre has put on healing characters. In 3d variety always injurious— 
hyd. of potass with opium beneficial. In 4th, always beneficial, though 
sometimes produces febrile mercurial irritation, when it should be given up. 
In 5th, antiphlogistic treatment and large doses of mercury, ^which should 
be discontinued if slough becomes dark. In 6th, if given at all, should 
be combined with large doses of opium, and an anodyne local treatment. 
7th, Not till sore puts on a healing character, when it hastens cicatrization, 
and then very cautiously, from susceptible state of system. 8th and 9th, 
Mercury decidedly contra-indicated ; where there is fever and excitement, 
free bloodletting, &c. ; but where there is constitutional cachexia and de- 
bility, hyd. potass, with opium and sarsaparilla internally, with local anti- 
^logistics. 

Worts and Fungi. — If irritable, must be quieted before having recourse 
to stimulant applications. When indolent, wash with dilute llq. chlorid. 
sodtt) then dust with calomel. In a variety which is flat or rounded and 
comparatively even, mercury of striking utility ; Dr Wallace has never seen 
it resist mercurial treatment. 

Bubo. — Hunter was of opinion that their resolution depended upon the 
quantity of meieury that could be made to pass through them. Dr Wallace 
held similar views. Primary syphilitic bubo may be resolved in 99 cases 
oat of 100, if mercury be properly employed, and its operation assisted by 
rest, abstinence, laxatives, and cooling lotions, Dr Hocken coincides in 



284 



ON THE TRBATMENT OF SYPHILIS. 



this, but thinks it should not be employed where acute mflammation exists,, 
or where patient is plethoric, until tliis has been reduced by rest and blood- 
letting. Locally, on Malapert's plan, of great use both in first stage and 
after suppuration. Remove epidermis, and apply for two hours with a 
bandage a piece of lint soaked in a lotion of hydmrg. bichlor. ^Jm aquc 
distill, ^j. An eschar follows, which must be treated on common suigical 
principles. In chronic bubo, friction with ioduret of mercury ointment 
(hyd. proto-iod. '3j., adip. §j.) or compresses soaked in tr, iodinii gj^ aque Jii. 
Open or ulcerating buboes to be treated on the same principles as primary 
chancres. 

Constitutional Syphilis, — Dr Hocken adopts the division into secondary 
(attacking skin, mucous membranes, eyes, testicles) and tertiary (tuberoles 
of skin and cellular tissue, affections of the bones, periosteum and fibrous 
tissue, &c. &c.) ; in both of these mercury and iodine are requisite. As a 
general rule, Dr H. regards the mercurial treatment as best adapted for the 
secondary ; the treatment by hyd. of potass for the tertiary group. 

All the diseases of the skin reqiiire antiphlogistic treatment in the early 
stages, and then yield in general either to a mercurial treatment or that by 
hyd. of potass. 

Skin diseases we shall class in two groups, according as they are most 
benefited by mercury or by hyd. of potass, remarking that in none is mer- 
cury to be used during the acute stage. 



Hyd. of Potass. 
Vesiculff. ) Nutritious Diet 
Bullae. j Opium. 
Pustule. When severe, as above, 



and 



Mercury. 

Papule. (Also weak lotions of cor- 
rosive sublimate locally.) 

Squame. (Locally — ung. hyd. nit.- 
ox. or sol. bichlor. hydrarg.) 

Exanthemata. 

-FwMre*.— Mercuiy. [In these we have found great benefit from araenic, 
where both mercury and iodine had failed.] 

Condylomata,-— V^q;^! with dilut. solut. of chlor. of soda, and dust with 
calomel ; mercury internally. 

Affections of Mouthy Throaty and Nostrils. — ^AU the simple sores, when 
brought into a healthy condition, are beneficially influenced hy mercury. 
Sloughing sore throats should be treated antiphlpgistically, when the patient 
can bear it ; when occurring in broken-down constitutions, with iodide of 
potass, sarsaparilla, and opium. When the ulcer has taken on a healing 
action, cicatrization is promoted by mercury. 

Tertiary Symptoms.— -Mercury inefficacious. Hyd. of potass beneficial, 
especially in diseasts of the bones, fibrous tissue, and joints ; also in early 
stage of disease of bones of nose, palate, or face. The ung. hydraig. nit.- 
oxid. may be used locally. 

Syphilitic Tubercles. — ^In indolent syphilitic tubercles, a combination of 
iodine and mercury may be employed. (Ricord's formula was one of the 
followmg pills daily, on the fifth day two pills are given ; the mercury is 
soon dropped, and the treatment concluded by hydriodate of potass : Hyd. 
proto-iod. gr. j. ; ext. conii gr. v. ; pulv. opii gr.'ss.) 

The next part of Dr Hocken's paper is devoted to the method of em- 
ployment of mercury and iodine, and is so meagre, that we shall substitute 
for it an abridgment of the views of Desruelles^ CuUerier, Ricord, Biett, 
and the other authorities in this disease, with a selection of the formulc 
employed by them. Calomel is chiefly employed when a speedy and 
iwwerful efllct L$ required. 



J 



ON THB TRBATMBNT OF SYPHILIS. 285 

Bidihnde of Mercury is strongly recommended by Dzondi and Dupuy- 
tren, chiefly for the treatment of constitutional symptoms. The fbrmer 
began by giving one-fifth of a grain, and increased it so that in thirty days 
the patient took a grain and a half. Dupuytren was of opinion that small 
doses were more efficacious than larger ones ; he rarely exceeded the sixth 
of a grain for a dose, usually giving one of the following pills three times 
a- day. B». hydraig. bichlorid. gr. ii. ; pulv. opii gr. viii. ; gum. guaiaci Sss. 
M. ft. pill. xvL* 

PiU, Hydrarg^ — The action of these is well known, and they are perhaps 
as good a remedy as we can employ ; pills made of mercurial ointment as 
recommended by Sedillot are milder, and sometimes agree better with the 
stomach. 

'Ql, Ung. hydrarg. fort. 3i. ; sapon. Hisp. 9ii. ; pulv. althee et 
mucilag. q. suff. ft. pill, xxxvi. gr. iv. in singulis ; ii.-iii. quotidie pro dose. 

Proto-Ioduret. — It is especially useful in secondary syphilis, tubercles, 
and exostoses. The following is the formula of Cullerier. R. hydrarg. 
proto-iodureti gr. xii. ; pulv. opii gr. vi. ; gum. guaiac. 3j. M. ft. pill. xxiv. 

Iodine, — Dr Wallace found the hyd. of potass to agree better than pure 
iodine. Ricord begins with ten grains daily, and in divided doses, and 
gradually increases it. 

Dr Hocken concludes with a review of the comparative merits of the 
remedies, and his conclusions are as follows : — 

1. That mercury and iodine are the two main remedies for the treat- 
ment of syphilis. 

2. That neither is a specific, and neither can be used empirically.. 

3. That mercury is adapted to nearly all the forms of primary syphilis, 
especially to the indurated. 

4. That in constitutional syphilis, it is applicable to a great majority of 
the secondary, but either hurtful or useless in the tertiary. 

5. That iodine is inert in almost all the varieties of primary syphilis, with 
the exception of some forms of phagedsna ; that it is less valuable than 
mercury in the secondary class, except in cases of a hectic and debilitated 
constitution ; that in tertiary symptoms it is more valuable than mercury. 

6. That mercury and iodine are advantageously combined in cases pre- 
senting a combination of secondary and tertiary diseases. 

7. That when mercury is employed, the mildest constitutional effect 
capiible of overcoming the disease should be preferred. 

8. That the only form of iodine applicable is the hyd. of potass, which 
should be given in moderate doses. 

9. That, however valuable hyd. of potass may be in certain forma. It 
never can be substituted for mercury in the treatment of syphilis. 



MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN* 
Risk Qitending an Tnjeetums into the Uterine CutUy. 

In a case of floor aUras^ Hoormaon observed that immediately on injeetinig 
a deooctioa of walnat leaves into the nterus the patient eomplaUwd of 

* The ejanutttiMfntfaeoajambadtmtedCtriU 
soluble, and not so entlj deeomiMMed, seeing mofe qnlMf, sad vidMWt fndm^ng 
paiiM 0t Ae stewaffc . 1^ Hj&mt^ efmutnd gr, xsir, ; mbommiu mwiiaL iuL ; 
giuiaci gum. JfiL ; cxC aoMihi 3iiL ; <C aiM K^ xxiv. M. nudfafp ^ s. vcft. 
piU. Goec Oae sr two mice tfr tkffw ciflMa a^di^^ i;»»diiall|r iflocMifig 



286 USE OF THE TAMPON. 

violent pAin in the nbdomen, and an attack of metroperitonitis'enBaed which 
required energetic treatment for its removal. Examples of the same result 
of injection occurred twice to Bretonneau, who presumed that the disease 
arose from the injected fluid passing through the Fallopian tuhes into the 
peritoneal sac. He found that on injecting copiously and forcibly into the 
uterus of the dead subject, in two experiments the fluid passed through 
the Fallopian tubes ; in one the injection returned through the uterine 
vessels (!), and in six it repassed between the syringe and the cervix uteri. 
'-'Schmides Jahrb. B. 80, S. 41. 



Use of the Tampon for the Cure of Utero-Vaginal Blennorrhtta, 

HouBMANN afiirms that the irritation excited by the secreted matters often 
keeps up the flow ; he therefore considers it advantageous to separate the 
sound from the diseased parts in order to keep off the morbid secretions, 
and for this purpose he has found plugging the chief, and in some instances 
the only, means of cnre. The author recommends the tampon to be made 
of charpie, if it is to be placed high in the vagina, but as soon as the parts 
can be kept dry, this material is to be changed for prepared wool, which can 
be introduced by means of a ** porte-mSche," in larger or smaller dos^ls, so 
easily as to be done by the patient herself. Thirty-eight cases of blennor- 
rhoea of different kinds have been treated in this manner with the most 
complete success. The tampon has been resorted to in females of all ages, 
and even in those in whom the parts were in a high state of inflammation. 
In these latter cases, and where the person was very young, the plug was 
slightly smeared with oil. If the flow was very copious, the cotton was 
changed twice a- day. No injections were required, the most essential 
point being to keep the parts as dry as possible. The same treatment was 
adopted and proved successful in blennorrhcea of the rectum. — Schmid^i 
Jahrb. B. 31, 8. 834. 



Trismus Neonatorum treated toitk Mutk* 

An epidemic, trismus neonatorum^ has been recently observed by Cderach- 
jold in the lying-in hospital at Stockholm, and Levy in the Freidrich's 
hospital at Copenhagen. Of 22 cases in the practice of the latter, 20 died ; 
in 15 a post-mortem examination was made, and in 14 inflammation of the 
nmbilical arteries was observed. In general both arteries were affected, 
especially in that part of their course which runs along the sides of the 
bladder ; the peritoneum in their neighbourhood was strongly injected. 
The canals of the vessels were dilated, and filled with a dark purulent fetid 
matter ; their parietes were frequently adherent to the omentum or intes- 
tines, and appeared somewhat thicker and darker than usual. In several cases 
perforation of the vessels with efi^usion of pus into the pelvic portion of tbs 
peritoneal sac was found. Thorston states that he has found the internal 
administration of musk and the external application of the unguent, cine- 
rcum highly useful. — Fricke und Oppenheim's Zeitschrift, Bft. 9. 



Keirmiss Mineral in Pkuro-Pneumonia in Children, 

GuGRSAMT has found that in this disease the frequency of the pube and 
inspiration, and the severity of the local symptoms^ are gradually diminished 
by the use of the kermes mineral, given in doses of from two to tliree gnuiMS 



CHANGES IN RAIN-WATER. 287 

tliree or four times in twenty*four hours, for children five or six years old, 
-Journal fur Kinderkrank, B. i. Eft. 2. 

On Testing the Qualities of a Nurse^s Milk. 

Deveroie, inspector of the institution for nurses in Faris^ has given his 
conclusions as to the quality of the milk in reference to its microscopic 
characters. The milk of the human female contains corpuscles of three 
different sizes. That which contains the lai^est globules is the m^t nutri- 
tive, but milk containing those of a moderate size is the most frequently 
met with. The milk with large globules is found chiefly, though not 
without exception, in wompn of the sanguineo* lymphatic temperament. 
There is sometimes a remarkable difference between the milk of the two 
breasts, which it appears often depends on the child being permitted to suck 
the one breast in preft^nce to the other. When the milk of one nurse is 
found not to agree with a child, the microscope may be of use in determin- 
ing whether or no the milk of a second is not apparently of exactly similar 
quality ; but there are many changes which it undergoes that the micro- 
seope cannot show. — Gastette M^tcaky Fevrier 1844. 



FORENSIC MEDICINE AND MEDICAL POLICE. 

Meam of Correcting the Changes which take place in Rain -Water kept in 
Cisterns newly constructed with Lime. By M. D'Arcet. 

A niopRiETOR in the country, who had no other water but tliat obtained 
£^>m a bad draw-well, determined to erect a cistern which should receive 
ail the rain-water that dropped from the roofs of his houses. The cistern 
vas accordingly built of stone, and lined with tiles united by mortar. In 
process of time the cistern was filled, but the water which was taken from 
it had a greenish tint, and was so charged with lime, that animals refused to 
drink it, and it could not even be used for watering flowers or shrubs, as it 
lefi; them covered with a white coating. M. d'Arcet was requested to give 
his advice, as to how these changes in the water could be prevented. He 
recommended the cistern to be emptied and sponged, to render it as dry as 
possible, with the view of saturating the lime with the lees of oil, hot 
linseed oil, or some other fatty composition, according to the method which 
we are told by Vitruvius and Pliny was pursued by the Greek and 
Roman architects. M. d'Arcet, however, found on descending into the 
cistern, that the lime was so saturated with water, which continued to 
distil from it drop by drop, that it was in fact impossible to dry it 
fluificiently for the purpose ; he therefore relinquished this attempt, and 
resolved to endeavour to convert the lime into a carbonate, and thus render 
it unaasailable by water. A small brick furnace was erected in the cistern, 
in which a hectolitre of charcoal (6105 cub. in.) was burned every day 
for a week, the cistern being kept nearly closed during the day, but freely 
exposed to the air at night. A few grains of the lime were scraped off 
^ly, fi»r the purpose of examining what change had taken place in it ; in 
less than eight days, it was found that the water with which it was 
mingled no longer pre3cnted the characters of lime-water, nor decomposed 
the muriate of ammonia ; for further secarity, however, the charcoal was 
burned in the cistern for a week longer ; at the end of that time it was 
thofoughly cleaned out, and when filled with rain-water, \he fluid was 
foond sufficiently pure to serve for experiment at the laboratory of the 
Royal Mint instead of distilled water. An instance exactly similar to the 



288 MEDICAL MEMORANDA. 

preceding is mentioned by the same author, where, for the purpose of 
correcting the water, twelve kilogrammes (about 28 pounds) of animal 
charcoal were thrown into the cistem ; this had the desired effect, and 
four years thereafter, without the charcoal being renewed, the cistem still 
furnished water sufficiently good for all domestic purposes. — Annaks 
d'Hygiene, Ayril 1844. 



Part IV.— MEDICAL MEMORANDA. 



On the Time required for the Transit of Coins and the like through the Intes- 
thiesy when swaUowed accidentally. 

As parents, and even the junior members of the profession, are apt to be 
alarmed by children accidentally swallowing objects which are given to 
amuse them, such as pebbles, leaden bullets, coins, &c., should you consider 
the following communication to deserve a place among your memoranda, it 
may perhaps be the means of quieting the apprehensions of those who may 
be called, and have not previously been concerned, in such cases. 

On the 2d of June of the present year, I was hurriedly sent for by Mr 
M., who became much alarmed in consequence of one of his children, a 
boy three years old, having swallowed a farthing. As I was informed that 
after the coin had disappeared the child had no cough nor difficulty in 
swallowing, I was satisfied that the foreign body had passed into the 
stomach, and that it would in due time be. evacuated from the bowels 
without any detriment to the little patient. Of this, however, the parents 
were not a little sceptical, and became anxious lest the detention of copper 
in the body might prove deleterious. To allay their apprehensions, there- 
fore, some infusion of senna was administered to the child every third 
morning to accelerate the expulsion of the coin, which happened on the 
seventeenth day of the same month. When swallowed it was quite bright, 
but after its expulsion it was of a dark colour. It is unnecessary to state 
that there was no uneasiness complained of during its detention. Pending 
the transit of the farthing in the present case, two other instances were re- 
lated in which each of the children swallowed a similar coin ; but, unlike 
what had occurred in the first child, in each of the latter the farthing was 
evacuated on the thii*d day. Some time previously each of two other 
children, about the same age, swallowed a half-sovereign, which in both 
instances was retained for three months. Dr A. T. Thomson I'elates two 
cases in which lai^e coins had been swallowed ; one of these was that of a 
boy, who swallowed a penny piece, which did not make its appearance for 
six months thereafter ; the second was a younger boy, who also swallowed 
a similar coin, but, unlike what happened in the first instance, it escaped 
after two months' detention. In both instances the coins were much 
eroded, but they exerted no injurious effect on the health of the children. 
Dr Paris mentions a case in which, with a suicidal intent, six penny pieces 
were swallowed, and they remained six years in the intestines ; and Dr 
Baillie records a case in which, on dissection, he found embedded in a pouch 
in the stomach a coin which had been swallowed soi^e considemble time 
previously. Wjf*'tJAMPBELL, M. D., 

Lecturer on Midwifery, &c. 

12th July 1844. 

Printed by OUver ii Bojd, Tweeddale eonrt, II I gh Street, Bdii>borgh. ^ 



( 



THE 

NORTHERN 
JOURNAL OF MEDICINE. 



No. v.— SEPTEMBER 1844. 



Part I.—ORIGINAL ARTICLES. 



Case of suspected Poisoning by an Over-dose of Tartar Emetic, 
sent ovt by a Non-professional Dispenser. By Ebenezer 
Skae, M. D., of Leven, Fifeshire. 

The following outline of a case, in which death was suspected to 
have been occasioned by an over-dose of tartar emetic, besides 
presenting some features of interest in a toxicological point of 
view, appears to furnish a very striking example of the disas>^ 
trous consequences which are calculated to result to the commu- 
nity, from the dangerous but too prevalent practice pursued in 
this country, by individuals undertaking the retail and dispensing 
of drugs possessing the most energetic and potent qualities, 
without their having received any competent instruction on the 
nature and properties of therapeutic agents, and who are conse- 
quently in a state of comparative ignorance, both as to their 
uses, and the doses in which they can be safely administered. 
To what extent an enlightened and a professedly philanthropic 
le^lature is responsible for the continuance of a practice fraught 
with such serious contingencies, it is not my present object to 
inquire. 

On the morning of Friday the 21st of January 1842, about 
three o'clock a. m., I received a hurried request to visit J. J., 
who resided within a short distance of me, and who, I was 
informed, was to all appearance expiring. On my arrival at his 
dwelling, a few minutes afterwards, I found that he was dead. 
He was a man of short stature, of robust habit of body, and 
about forty-five years of age. The external aspect of the body 
presented nothing remarkable, with the exception of a tumefied 
and congested appearance of the integuments of the face and 
neck, and considerable distention of the abdomen. On making 
some inquiry regarding the nature of the symptoms which had 
preceded death, the statements I received from the family were 
far from being intelligible and satisfactory as accounting for the 

2o 



290 CASE OF SUSPECTED POISONING 

cause of death. My judgment of the case, indeed, rested on a 
knowledge of the following facts, some of which had been a 
matter of personal observation to me in the course of my former 
professional attendance on the deceased, and the rest were com- 
municated to me by his family. 

For several years, at a previous period of his life, he had been 
much addicted to the intemperate use of alcoholic stimuli, during 
which time he was repeatedly under my care, in consequence of 
his having been affected with attacks of delirium tremens; but 
four years previous to his death he had joined the Total Abstin- 
ence Society, and I had reason to know that, up to the last week 
of his life, he maintained habits of the strictest sobriety. On 
" Old Hansel Monday," which is invariably observed throughout 
Fife as a holiday, especially among the working-classes, and 
which occurred that year on the 17th of January, being the 
Monday of the same week in which he died, he unfortunately 
broke through his good resolutions, and foolishly indulged in the 
use of liquor till he became intoxicated ; on Tuesday and Wed- 
nesday he continued his debauch ; on Thursday morning at ten 
o'clock, feeling himself suffering greatly from the usual effects 
of intemperance, he sent for an emetic and took it, as had been 
his former practice under similar circumstances, when he had 
always experienced considerable relief by its employment. The 
action of the vomit commenced eight or ten minutes after its 
exhibition, and was stated to have been powerful, which was 
followed about two or three hours afterwards by profuse 
diarrhoea, and this latter symptom continued with little inter- 
mission up to the moment of dissolution, which took place six- 
teen hours after the emetic had been administered. During the 
latter part of the day, he had complained very much of pam in 
his throat and in the region of the stomach, and he appeared to 
labour under great general uneasiness and restlessness, with oc- 
casional sweatings and great prostration of strength. He had 
been very fretful under his sufferings, and had incessantly im- 
portuned his wife and family to send for my assistance, which 
they had as steadily refused or evaded, from a belief that his 
complaints were of the same nature as he had formerly endured 
from similar causes, and that they would gradually abate, as they 
had frequently done on previous occasions. At length his im- 
patience to see me had become so strong, that he declared he 
" would go to the doctor himself;" and by an unexpected exer- 
tion of his own strength, he contrived to slip out of bed, when 
he almost instantly fell prostrate on the floor in a state of insen- 
sibility. On this his wife and family immediately alarmed the 
neighbours and sent off for me. On replacing him in bed, life 
appeared to be extinct ; a fact but too evident to myself on my 
arrival a few minutes afterwards. 

On carefully considering these circumstances, I experienced 



BY TARTAR EMETIC. 291 

great difficulty in forming a satisfactory conclusion as to the 
character of the symptoms which had resulted fatally in this 
case. From all that I could learn^ I had no reason to believe 
that the characteristic phenomena of delirium tremens had been 
present during life. That any serious lesion of an apoplectic 
nature had taken place within the cranium, appeared at least 
as improbable, from the leading features of such a seizure having 
been absent in the case. There had also been an entire absence 
of any indications that could lead me to suspect the existence of 
any thoracic disease of a rapidly fatal nature. The train of 
symptoms appeared to imply a strong probability that the seat 
of the disorder was in the abdominal viscera, and moreover 
that the disease might have been enteritis; at the same time, I 
could not divest my mind of a suspicion that the effects of the 
emetic had some connexion with the morbid phenomena, which 
had been developed subsequently to its administration ; — ^a sus- 
picion, indeed, which was in the first instance suggested to me 
by the language of the widow of the deceased, who, in reply to 
my question as to how the vomit had acted, stated that it had 
done so very powerfully, and that " he/' to use her own words, 
" appeared never to have got above it." Under the influence 
of this impression, I was naturally led to make some inquiry re- 
garding the appearance of the einetic which had been given, and 
also where it had been purchased ; when I was informed that it 
had been obtained from a grocer's shop where drugs of different 
kinds were sold, and that it consisted of a white powder, of a 
similar bulk to that of the brmun vomits thejr had formerly been 
accustomed to get from the same shop. This information led me 
at the moment to infer, either that the vomit in question had con- 
sisted of sulphate of zinc in powder, or that possibly, from some 
mistake, an overdose of tartar emetic had been sold by the grocer's 
shopkeeper who had supplied it. As the family, and especially 
the widow, appeared to attach considerable suspicion to the vio- 
lent action of the emetic, inquiry was made the following day at 
the shop where it had been purchased, when the shopman at 
once admitted, in terms exhibiting no small degree of confidence 
in his own knowledge of such matters, that he had supplied them 
with two drops